CASE 2: RHEUMATIC HEART DISEASE

1. CASE 2: RHEUMATIC HEART DISEASE

2. 28 y/o, Female • Chief Complaint: Dyspnea

3. History of Present Illness

4. Past Medical History • (+) frequent streptococcal throat infection in childhood • At age 6- Valvular heart disease w/ monthly injections of Benzathine Penicillin

5. Family History • (+) HPN- grandfather • (+) Heart disease- father

6. Physical Examination • 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

7. Physical Examination • Supple neck, distended neck veins at 4-5cm at 30 0angle • 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

8. Physical Examination • Globular abdomen, liver is palpable • Extremity: Grade 2 bipedal edema

9. Salient Features • Dyspnea • Underwent dental procedure • Productive cough with yellowish sputum accompanied by colds • Pricking chest pain radiating to the back lasting for more than 30 minsaccuring 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

10. 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

11. 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

12. Salient Features • Palpable liver • Grade 2 bipedal edema

13. Laboratory Tests

14. Chest X-ray • Cardiomegaly with features of mitral valve pathology • Pulmonary edema • Haziness at the R paracardiac border

15. ECG • Atrial Fibrillation with rapid ventricular response • Non specific ST-T wave changes

16. 2D Echo • 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