CASE 2: RHEUMATIC HEART DISEASE

28 y/o, Female Chief Complaint: Dyspnea

3 days PTA • Underwent dental procedures

2 days PTA •Productive cough with yellowish sputum accompanied by colds•Pricking chest pain radiating to the back lasting for more than 30 mins accuring even at rest•Fever T 38 0C , joint pain and myalgia

1 day PTA •Increase severity of symptoms with accompanying dyspnea and easy fatigability

History of Present Illness

(+) frequent streptococcal throat infection in childhood

At age 6- Valvular heart disease w/ monthly injections of Benzathine Penicillin

Past Medical History

(+) HPN- grandfather (+) Heart disease- father

Family History

Drowsy, in respiratory distress, prefers the semi sitting position

BP-130/60 PR-124bpm CR- 135bpm,irregulary irregular

RR- 40cpm T 38.50C Cold, clammy extremities, no active

dermatoses No nasoaural discharge with alar flaring Moist buccal mucosa, hyperemic posterior

pharyngeal wall, tonsils not enlarged

Physical Examination

Supple neck, distended neck veins at 4-5cm at 30 0 angle

Symmetrical chest expansion, (+) supraclavicular retractions, coarse crackles over both lung fields

Dynamic precordium, AB at 6th LICS AAL, (+) heave at L lower parasternal area, (++) impulse at the 2nd LICS

Apex: S1 vary in intensity, grade 3/6 holosystolic murmur radiating to the axilla; Normal S2, opening snap and grade 3/6 diastolic rumbling murmur

Base: pulmonic component of S2 is loud grade 3/6 diastolic blowing murmur

Physical Examination

Globular abdomen, liver is palpable Extremity: Grade 2 bipedal edema

Physical Examination

Dyspnea Underwent dental procedure Productive cough with yellowish sputum

accompanied by colds Pricking chest pain radiating to the back lasting

for more than 30 mins accuring even at rest Fever, joint pain and myalgia (+) frequent streptococcal throat infection in

childhood At age 6- Valvular heart disease w/ monthly

injections of Benzathine Penicillin

Salient Features

FH: (+) HPN- grandfather, (+) Heart disease- father

PE findings: drowsy, in respiratory distress, prefers the semi sitting position

BP-130/60 PR-124bpm CR- 135bpm,irreg RR- 40cpm T 38.50C Cold, clammy extremities hyperemic posterior pharyngeal wall, tonsils

not enlarged

Salient Features

distended neck veins at 4-5cm at 30 0 angle Symmetrical chest expansion, (+) supraclavicular

retractions, coarse crackles over both lung fields Dynamic precordium, AB at 6th LICS AAL, (+)

heave at L lower parasternal area, (++) impulse at the 2nd LICS

Apex: S1 vary in intensity, grade 3/6 holosystolic murmur radiating to the axilla; Normal S2, opening snap and grade 3/6 diastolic rumbling murmur

Base: pulmonic component of S2 is loud grade 3/6 diastolic blowing murmur

Salient Features

Palpable liver Grade 2 bipedal edema

Salient Features

CBC

Hgb- 120 N ESR - >100mm/hr ↑

Hct- 40 N ASO- >200IU/L ↑

Plt- 305 N

WBC-19.9 x109/L ↑

Seg-0.91 ↑

Lympho-0.08 ↓

Laboratory Tests

Cardiomegaly with features of mitral valve pathology

Pulmonary edema

Haziness at the R paracardiac border

Chest X-ray

Atrial Fibrillation with rapid ventricular response

Non specific ST-T wave changes

ECG

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Mitral Stenosis, moderate to severe Mitral Regurgitation, moderate Aortic Regurgitation, moderate LV and RV dilatation Dilated LA and RA w/ no evidence of

thrombus Dilated main pulmonary artery

2D Echo