medInUSA

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Just did a strange U world question:

old lady, 2 month h/o fatigue and dyspnea on exertion. BP is 180/80, pulse 100, Resp is 21. There is a 2/6 systolic murmur in the 2nd left intercostal space. ON EKG sinus tachy with nonspecific ST-T changes. Hb 8.1 and MCV is 73

What's the next best step in the management of this patient?

a) Echo
b) Colonoscopy



Next step you would do a colonoscopy, since she is suffering from iron deficiency anemia secondary to GI bleeding.

But what I don't understand is if the lady has been bleeding for two months, why in the world is her BP so elevated. Shouldn't she be hypotensive from all the blood loss.

Surprising this issue is NOT addressed in their explanation.
 
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medInUSA

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Sorry, Never mind, just realized the answer. After giving it some thought.

Only the systolic is elevated, not the diastolic. The wide pulse pressure represents hyperdynamic circulation b/c of the anemia.
 

Scaredshizzles

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Just did a strange U world question:

old lady, 2 month h/o fatigue and dyspnea on exertion. BP is 180/80, pulse 100, Resp is 21. There is a 2/6 systolic murmur in the 2nd left intercostal space. ON EKG sinus tachy with nonspecific ST-T changes. Hb 8.1 and MCV is 73

What's the next best step in the management of this patient?

a) Echo
b) Colonoscopy



Next step you would do a colonoscopy, since she is suffering from iron deficiency anemia secondary to GI bleeding.

But what I don't understand is if the lady has been bleeding for two months, why in the world is her BP so elevated. Shouldn't she be hypotensive from all the blood loss.

Surprising this issue is NOT addressed in their explanation.

There is also an oft-tested, never seen relationship between colonic AVMs and aortic insufficiency....They might have been suggesting aortic insufficiency with that wide pulse pressure and murmur along the left border of the sternum...
 

chemist157

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There is also an oft-tested, never seen relationship between colonic AVMs and aortic insufficiency....They might have been suggesting aortic insufficiency with that wide pulse pressure and murmur along the left border of the sternum...
Wouldn't that be a diastolic murmur?
 

Scaredshizzles

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Wouldn't that be a diastolic murmur?

It should be, but there is some kind of mistake regardless here, because aortic stenosis is always described as being loudest in 2nd right intercostal and mitral regurg said to be loudest at the apex... (not that in reality you can 100% always tell where it is quite loudest.) Either uworld messed up or the poster transcribing it did.
 
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medInUSA

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It should be, but there is some kind of mistake regardless here, because aortic stenosis is always described as being loudest in 2nd right intercostal and mitral regurg said to be loudest at the apex... (not that in reality you can 100% always tell where it is quite loudest.) Either uworld messed up or the poster transcribing it did.
Neither the Uworld nor the transciber made a mistake on this one.

The reason for the murmur and wide pulse pressure is the hyperdynamic circulation b/c of the anemia.

from wikipedia:

"Hyperdynamic circulation is an increase in pulse pressure and blood pressure caused by certain physiological and psychiatric illnesses. The patient often presents with a collapsing pulse and sinus tachycardia. Some of the possible causes of hyperdynamic circulation are listed below:

renal disease
volume expansion
Anaemia
Anxiety
AV fistulae
Beriberi
Erythroderma
Exercise
Hepatic failure
Hydrocephalus[1]
Hypercapnia
Paget's disease
portal hypertension
Pregnancy
Pyrexia
Thyrotoxicosis
Vasodilator drugs"
 

Scaredshizzles

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Neither the Uworld nor the transciber made a mistake on this one.

The reason for the murmur and wide pulse pressure is the hyperdynamic circulation b/c of the anemia.

from wikipedia:

"Hyperdynamic circulation is an increase in pulse pressure and blood pressure caused by certain physiological and psychiatric illnesses. The patient often presents with a collapsing pulse and sinus tachycardia. Some of the possible causes of hyperdynamic circulation are listed below:

renal disease
volume expansion
Anaemia
Anxiety
AV fistulae
Beriberi
Erythroderma
Exercise
Hepatic failure
Hydrocephalus[1]
Hypercapnia
Paget's disease
portal hypertension
Pregnancy
Pyrexia
Thyrotoxicosis
Vasodilator drugs"

Yes, it does match the description of a flow murmur, but a systolic of 180 with a pulse of 100 is just not very realistic in your anemic patient. The pulse would be higher and the systolic would not be anywhere near 180....It's just another one of those poor uworld descriptions...But they are good practice anyway because the real exam has some poor questions too.