Acute rheumatic fever and rheumatic heart disease Quiz: Ace Your Exams
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A 7-year-old girl presents to her pediatrician's office for evaluation of abnormal movements and atypical frequent episodes of crying. Parent reports that the patient has had intermittent “jerky” movements of the upper extremities over the past 2-3 days. Parent also notes intermittent facial twitching as well as grimacing. The “crying spells” occur randomly and are not brought on by preceding incidents. These episodes are unusual for this child, whose parents describe her as typically happy. The patient has no significant past medical history, though she did have upper respiratory infections in the winter. Temperature is 37°C (98.6°F), blood pressure is 107/71mmHg, pulse is 98/min, respiratory rate is 20/min, and oxygen saturation is 98% on room air. Physical examination demonstrates evidence of abrupt nonrhythmic movements of the upper left extremity. Erratic movements of the facial muscles and intermittent grimacing are also noted. Palpable nodules are present on the volar aspect of the bilateral wrists. Antistreptolysin O (ASO) titers are positive. Which of the following parts of the physical examination is most likely to be abnormal given the likely underlying diagnosis?
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