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DEPARTMENT OF MEDICINE
CASE PRESENTATION:
CHRONIC RHEUMATIC VALVULAR HEART
DISEASE CAUSING MITRAL REGURGITATION,
AORTIC REGURGITATION AND
PULMONARY HYPERTENSION
CASE HISTORY:
RESPIRATORY SYSTEM:
There is history of episodic dry cough and
breathlessness on exertion. There is no history of sore throat,
hoarsness, whooping cough or blood in the sputum.
ALIMENTARY SYSTEM :
No history of dysphagia, vomiting, abdominal pain,
hematemesis, diarrhea or constipation.
MUSCULOSKELETAL SYSTEM:
There is history of pain in small joints of hands
about six months back.
Since 2 months Bilal has again developed mild pain in the
ankle joint and small joints of hands.
SKIN:
There was history of small suppurative areas on planter
aspect of the feet which resulted in pain in ankle joint area.
There is no history of rash, subcutaneous nodules on
any part of the body.
CNS:
There is no history of involuntary movements,
Headache, vertigo or numbness of hands and feet.
GENITOURINARY:
No history of pain and burning during
micturition, bleeding in urine or pain in the flanks.
ENDOCRINE SYSTEM:
No history of excessive thirst, excessive appetite,
excessive urination, heat or cold intolerance.
TREATMENT AND ITS EFFECTS:
During this period of 2 months the patient has been going to
different doctors for treatment which used to give
temporary relief.
PAST MEDICAL AND SURGICAL HISTORY:
VACCINATION HISTORY:
The child is fully vaccinated against major diseases
according to the EPI schedule,
no additional vaccination was given.
1. EXAMINATION OF PULSE:
Pulse rate was 104 /min, regular in rhythm, high volume,
collapsing in character,wall of radial artery was not palpable.
Both radial arteries were equal in volume and same in timing.
There was no radiofemoral delay. Both posterior tibial
arteries were equal in volume and same in timing. There was
no systolic bruit over the axillary, subclavian, or
popliteal arteries. There was no Duroziez’s murmur on
auscultation or pistol shot femorals palpable, no capillary
pulsation in nails,lips and tongue. No varicose veins were
visible on calves and thighs.
2. EXAMINATION OF PRECORDIUM:
A.INSPECTION:
On inspection, there was slight bulging of the precordium
which is moving upwards with beating of the heart.
Apex beat was visible on the 6th intercostal space 1cm lateral
to the mid axillary line. No other visible pulsation in left and
right 2nd intercostal space or suprasternal notch. Although a
pulsation is visible in the epigastrium. There was no
engorgement of chest veins , no chest deformity or scar mark.
There was no deformity of the thoracic spine.
B.PALPATION:
Mitral area:
1st heart sound was not audible,2nd heart sound was
audible, there was Pansystolic murmur radiating to axilla
and was loud on expiration.
Tricuspid area:
2nd heart sound is audible. There was no murmur.
Pulmonary area:
2nd heart sounds was accentuated in Pulmonary area. No
murmur was audible. No spliting of second heart sound
Aortic area 1: Second heart sound was less loud in the aortic
area as compared to the pulmonary area.
Aortic area 2: 2nd heart sound was audible. Early diastolic
murmur was audible in the 2nd aortic area.
Examination of other systems did not reveal any
remarkable physical signs including:
that there was no strawberry tongue and the liver was
also not enlarged or tender.
DIAGNOSIS:
Based on History and Clinical Examination in my opinion
the diagnosis of this patient is Chronic Rheumatic Valvular
Heart Disease causing Mitral Regurgitation, Aortic
Regurgitation and Pulmonary Hypertension.
DIFFERENTIAL
DIAGNOSIS
I. RHEUMATIC HEART DISEASE:
⚫ Fever , Anorexia , lethargy
of streptococcal infection
⚫ Pancarditis: Palpitations, Chest pain, Cardiac enlargement,
subcutaneous nodules.
⚫ Sydenham’s Chorea (more common in females)
II. CONGENITAL HEART DISEASES:
Majority of these cases are diagnosed in early childhood.
Features include:
⚫ Central cyanosis
⚫ Pulmonary Hypertension
⚫ Clubbing of fingers
⚫ Paradoxical embolism
⚫ Reduced growth
⚫ Syncope
at finger tips
⚫ Janeway lesions
⚫ Digital clubbing
⚫ Hepatosplenomegaly
⚫ Varying murmurs
⚫ Fever
⚫ Arhtritis
⚫ Rash
⚫ Serositis
⚫ Hepatosplenomegaly
⚫ Valvular involvement
V. FELTY’S SYNDROME
⚫ Polyarhtritis
⚫ Neutropenia
⚫ Valvular involvement
⚫ Splenomegaly
⚫ Lymphadenopathy
⚫ Skin pigmentation
⚫ Recurrent infections
⚫ Nodules
VI- KAWASAKI DISEASE:
⚫ Red eyes
(strawberry tongue)
⚫ Swollen lymph nodes
⚫ Widespread rash
A- Major:
1. Carditis 2. Polyarhritis
3. Chorea 4. Erythema marginatum
5. Subcutaneous nodules
B- MINOR:
1. Fever 2. Arthralgia
3. Previous rheumatic fever
4. Raised ESR/C reactive proteins
5. Leukocytosis
6. Prolonged PR interval on ECG
C- REQUIRED CRITERIA:
Supporting evidence of preceding streptococcal
infection:recent scarlet fever, raised ASO or other
streptococcal antibody titre,positive throat culture
Diagnostic criteria:
⚫ 2 major criteria and 1 minor criteria
2. Aortic regurgitation
Collapsing pulse
Increased pulse pressure
Early diastolic, Systolic murmur
Austin Flint murmur
Bounding peripheral pulses
Quincke’s sign
Duroziez’s sign
de Musset’s sign: head nodding with pulse
3. Pulmonary hypertension
Elevated JVP
Loud P2
6. Arrhythmias
7. Severe Anemia
8. Pericardial effusion
9. Thromboembolism
Stroke
Ischaemic limb
INVESTIGATIONS
NON SPECIFIC: (evidence of systemic illness)
AR: Dilated LV
Doppler detects reflex
Pulmonary HTN:
PAP = 4×(TRV) 2 + RAP
Figure shows elevated Tricuspid
Regurgitation velocity consistent
With pulmonary hypertension .
TREATMENT
TREATMENT OF OUR PATIENT:
ACUTE ATTACK;
A) MEDICAL:
⚫ Diuretics: Furosemide
B) SURGERY:
⚫ EF is less than 60%
than 4.5cm
⚫ If pulmonary hypertension
or atrial fibrillation
AORTIC REGURGITATION:
SURGERY:
⚫ Acute severe aortic regurgitation e.g endocarditis
GENERAL:
Diuretic therapy for right heart failure
Long term oxygen for hypoxemia
Avoid excessive physical activity
Pneumococcal and influenza vaccination.
SPECIFIC:
Calcium channel blockers
Prostacyclin
Phosphodiesterase type 5 inhibitor
Endothelin antagonist(bosentan)
Atrial septostomy
ANY QUESTION?
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