CRIMEAN STATE MEDICAL UNIVERSITY

NAMED AFTER S.I. GEORGIEVSKY

DEPARTMENT OF THERAPY

Case History
TITOVA VALENTINA GRIGORIEVNA
Clinical Diagnosis:
Main Diseases: -CHRONIC RHEUMATIC HEART DISEASE, ACTIVE
PHASE 1st DEGREE,
-RECURRENT CARDITIS,
-OPERATED MITRAL HEART DEFECT WITH STENOSIS
PREDOMINANCE, (COMISSUROTOMIA 2001),
RESTENOSIS.

Complications: -ATRIA FIBRILLATION, CONSEQUENCES OF

CEREBRAL STROKE (1999)
-CHRONIC HEART FAILURE (II a)

Accompanying Diseases: ---

Chua Sook Yin

Group 428

PASSPORT DATA
Name: Titova Valentina Grigorievna
Sex: Female
Age: 50 years old
Family Status: married
Date of Admission: 20 - 09 2007

INQUIRY (Interrogatio)
Complaints:
Patient complaint of irregular heart beating during physical exertion(walking for 1015m),dyspnea at rest and during walking upstairs. Patient also complaint of edema of the leg at the end
of the day. The edema of legs decrease after diuretics. She also feel fatigue and malaise when doing
physical activity.
History of the present disease (Anamnesis morbi)
Patient often experienced angina during her childhood although there is no any arthralgia, she
did not appear to doctor and did not take any antibacterial treatment. At the beginning, during her second
pregnancy(when she was 28 yrs old), she was diagnosed as having valvular heart defect when the
physician listened to the heart. This diagnosis was further confirmed by ultrasound examination. But
soon after that she felt dyspnea and slightly increase in temperature. She went to Kiev for further
examination and the diagnosis as active rheumatic fever was made there. After diagnosis was made she
undergone conservative treatment without any surgical measures by injection of Bicillin 5 for every
year. Her 1st pregnancy was normal. Soon after the 2nd diagnosis was made, her dyspnea became
progressive (she felt dyspnea during physical exertion)
In 1999, she experienced severe dyspnea, arrhythmia and stroke due to thromboembolism of
cerebral vessels. She went to Kiev for consultation and the decision to make surgical correction of heart
defect (mitral stenosis) was made. In 2001 the mitral commissurotomia was done. Patient felt better for
some time after the operation although her heart rhythm was not normalized. But later she begins to
experience progressive dyspnea again. The dyspnea reappears.

History of life (Anamnesis Vitae)

The patient is the last child of her family. She has 8 brothers and sisters. She experienced quinsy
and angina during her childhood but not appear to doctor. As a result no any antibacterial treatment was

done. Her 1st pregnancy was normal. Symptoms only became manifested during her 2nd pregnancy. She
took Bicillin prophylaxis for every year after that.
There is no history of rheumatic fever among her family members. She had respiratory infection
when she still working. Shes not a smoker, and she doesnt drink alcohol. No history of trauma. She had
urolithiasis, cholelithiasis and cholecytitis. She undergone cholecystemia after operation on the heart.
Inspection
Patient present with facies mitralis. There is slight acrocyanosis of lips, colour on finger is
normal. She present with a little bit jaundice. There is no edema on the leg as patient under the course of
diuretics.
Palpation
Patients pulse rhythm is irregular. There is present of pulsus deficit and her pulse rate is difficult
to determined.
Auscultation
-1st and 2nd heart sounds are heard at all points.
-1st sound is increase more than 2 times then the 2nd sound at heart apex.
-There is palpitation of the heart.
-2nd sound is accentuated over the auscultatory points of pulmonary trunk.
-Pulsus deficit is determined.

INITIAL DIAGNOSIS
Reoccurrence of dyspnea and present of palpitation, absent of any major criteria of Jones now
but present of it(carditis) in the past suggest chronic rheumatic heart disease, active phase(?),and
carditis(?).

PLAN OF ADDITIONAL DIAGNOSIS

1. General blood analysis
2. Biochemical blood test
3. Rheuma test
4. Electrocardiogram, ECG
5. Ultrasound of heart.
6. Neurologist examination.
7. Chest X-ray
8. CT-scan

RESULTS OF SUPPLEMENTARY RESEARCHES AND THEIR CLINICAL

ESTIMATION
1)

General blood analysis

Erythrocytes 3,9 x 1012 / L
Hemoglobin 127 g / L
Leucoctyes 3,7x109 / L
Basophil 1 %
Eosinophils 1 %
Neutrophils Stab 6%
Segmented -62 %
Lymphocytes 30%

Conclusions: The result of general blood analysis is shows that there is slight decrease in leukocyte
count in the patient.

2)

Biochemical blood analysis

ALP

0,97mmol/L

Common protein 65
Sugar

--5,1 mmol/L

Potassium ion

--4,6

Prothrombin index 26
3)

Rheuma test
CRP

--1+

Gaptoglobin1,52
Seromucoid2,5
Conclusion: increase of C-reactive protein indicates that there is 1st degree of
activity of rheumatic fever.
4)

Electrocardiogram, ECG
-atrial fibrillation
-sign of ischemia
-heart rate -65/min

Conclusion : There is normosystolic atrial fibrillation with ischemic sign.

5)

Ultrasound of heart .
Opening of aortic valve-normal
Left atrium-4,8cm in diameter
5,8cm in diameter

Mitral ostium-1cm in diameter

Diastolic size of left ventricle-6,1cm
Width of posterior wall of left ventricle-0,8cm
Width of interventricular septum-0,8cm
Hypertrophy of left ventricle-absent
Diameter of right ventricle-2,
Ejective fraction - 42%

(norm:4-6cm)
(norm:4,9-5,5cm)

(norm:1,7-2,6)
(norm- 55 %)

Conclusion:
Cusp of miral valve in sclerotic changes
Scars of commissures present
Excessive mitral stenosis
Mild to moderate mitral regurgitation(revealed in Doppler)
6)

Neurologist examination.
-no affection of nervous system revealed.

7)

Chest X-ray

Mitral configuration of the heart.

Dilatation of left atrium,left ventricle.
Cardiac size exceed cardiothoracic ratio.
Slightly dilatation of right ventricle-suggest hypertrophy in pulmonary
circulation.

8)

CT-scan
Conclusion: There is present of shadow on right side of the brain which indicate presence of
stroke in the past.

FINAL DIAGNOSIS AND ITS SUBSTANTIATION

1) Complaints of patient:

- Irregular heart beat during physical exertion,

- dyspnea
- edema of the leg .

2) result of physical examination:

facies mitralis
acrocyanosis of lips
irregular pulse rhythm
pulsus deficit

3) findings of the additional investigation of the patient

i.
ii.
iii.

Rheuma test -CRP 1+

ECG
- normosystolic atrial fibrillation.
Ultrasound
a) Diastolic size of left ventricle-increased
b) Diameter of right ventricle-increased
c) Excessive mitral stenosis
d) Mild to moderate mitral regurgitation
e) Ejection fraction-decreased

iv.

Chest X-ray
a) Mitral configuration of the heart.
b) Dilatation of left atrium,left ventricle.
c) Cardiac size exceed cardiothoracic ratio.
d) Slightly dilatation of right ventricle

make it possible to formulate the following diagnosis:

Clinical Diagnosis:
Chronic Rheumatic Heart Disease, Active phase 1st degree; Recurrent
Carditis;

Main Diseases:

Operated Mitral Heart Defect with Stenosis

predominance(commissurotomia in year 2001)
Complications: -

Atrial Fibrillation consequences of cerebral stroke(1999)

-

Cardiac Failure IIA

Accompanying Diseases: --

TREATMENT
I.

Diet no. 10-- limitation of salts, fluid, animal fats should be kept.

II.
III.

Regime: Strict bed regime

Drug therapy ----

aetiological treatment of rheumatism, pathogenic treatment,

symptomatical treatment of heart failure .

1. Aetiological treatment.
Antibiotic therapy -- Benzylpenicillin sodium
-Biosynthetic, short acting
-Mechanism of action: bactericidal effect by inhibiting the bacterial cell wall synthesis.
-Side effects: allergic reaction
Rp.: Benzylpenicillin- natrii 1000000 UA
D.t.d N20
S. 1 mln U to dissolve in 5 ml of water for injections, IM, every 3-4 hours.
2. Pathogenic treatment.
Systemic synthetic glucocorticoid hormones---Predinisolone
-Mechanism of action --

slowing down process of regeneration and proliferation due to

inhibition of protein synthesis.

-Side effects: hyperglycemia, hypokalemia, edema.

Rp.: Tab. Prednisolone 0.005 N30
D.S. 1 tab per os 3t/day.
3. Symptomatic treatment of cardiac failure.
Loop Diuretic-Furosemide
-Mechanism of action: Inhibit activity of transport ATPase of basal membranes in epithelium
of renal tubules, inhibit Na+, K+, Cl- reabsorption
-Side effects: Hypokalaemia
Rp.: Tab. Furosemidi 0.04 N20
D.S. 1 tab per os 1t/day in the morning

Potassium preparation- Panagin

-Mechanism of action : restoration of normal potassium concentration.
Rp.: Dr. Panangin 0.025 N30
D.S. To introduce 1 tablet per os once daily after meals.
Cardiac metabolite drug- Riboxine
-Mechanism of action: Optimize energetic metabolism.
-Side effects: allergic reactions
Rp.: Sol. Riboxini 2%-5ml
D.t.d. N10 in amp
S. 1ml, IV
Prophylaxis
After administration of Benzylpenicillin sodium for 14 days, we should administer Bicillin-5
once a year for prophylaxis of relapse of rheumatic fever.
Rp.: Bicillin-5 1500000 UA
D.t.d N3
S. 1.5 mln to dissolve in 10 ml of water for injections, IM, 3 t/day, at 8 days intervals.

Chua Sook Yin

Group 428