1. Clinical case presentation
 A 9 year old male, hailing from Kerala, presented with complaints of:
 Cough and breathlessness since 2 years which was increased since the last 15
days
 palpitations since 15 days
 Fever , on and off since 15 days
 Joint pain, since 15 days
 Breathlessness
 insidious in onset,
 initially present on increased activity now present even with ordinary activity since
past 15 days .
 Breathlesness is not present on lying down
 No diurnal variation.
 No seasonal variation
 Not associated with bluish discoloration of skin or squatting episodes
 Breathlesness is associated with cough

2.  Cough
 associated with scanty mucoid expectoration since the past 15
dyas, non blood stained.
 Not associated with rise in temperature
 Not associated with wheeze
 No diurnal variation , not increased on exposure to cold(seasonal variation)
 Cough is associated with chest pain, which is present only during coughing,
pricking in type, present diffusely, non radiating.
 Palpitations
 Present even at rest.
 Not associated with chest pain
 Associated with dizziness but there was no loss of consciousness.

3.  Fever
 High grade
 Present on and off since 15 days
 Not associated with rigors
 Pain and swelling of the left knee joint since 15 days
 Associated with limitation of movement, the child could not walk due
to the pain
 Not history of trauma
 after a week the pain in the knee joint subsided, and the child had pain in
the left ankle joint and right elbow joint.
 No history of morning stiffness.
 pain subsided immediately after the initiation of treatment

4. Negative history
 no history of reduced urine output
 no history of pedal oedema
 No history of abdominal pain
 No history of recurrent sore throat.
 No history of rash or bleeding manifestations (petechial
hemorrhages, purpura)
 No history of recurrent respiratory tract infections
 history of weight loss present but could not be quantified

5. PAST HISTORY
 History of similar complaints in the past.
 3 years back he presented with fever associated with fleeting
type of joint pain , and was admitted in the hospital and
treated for the same.
 He was advised to take injections every 3 weeks until
the age of twenty five(suggestive of acute rheumatic
fever) but the injections were discontinued one year back
due to reasons unknown.
 No history of asthma.
 No history of contact with tuberculosis

6. BIRTH HISTORY
 No complications in the antenatal period
 Institutional delivery at term, normal vaginal delivery, baby cried
immediately.
 Birth weight- not known.
 No complications during the delivery
 No post natal complications. NO ICU admissions after birth.
 No problems during infancy.

7. DEVELOPMENTAL HISTORY
all milestones were achieved on time.
IMMUNISATION HISTORY
Immunisation up to date
OPV, BCG, DPT and boosters , Measles vaccine given.

8. DIET HISTORY
MEAL FOOD ITEM CALORIES PROTEIN
Morning 1 cup milk with sugar 127 4.1
2 biscuits
Breakfast 2 dosa , half cup dal 200 6
Lunch 1 cup rice 376 10
1 cup sambar
1 cup of vegetables
Evening snack 1 cup milk with sugar 87 3.3
dinner 2 roti 287 24
Half cup dal
1 fish
Calories requirement = 1620 kcal Protein requiremnt=33.2 g/day
Calories obtained= 1047 Obtained= 35 g
Defecit= 573 No defecit

9.  SOCIAL HISTORY
He is in 3rd standard. He performs averagely at school. He has
been held back a year due to missing school due to poor health
and his performance.

10. FAMILY HISTORY
 Non consanguineous marriage. No history of similar complaints in the family
 Socioeconomic status- Upper lower class as per modified Kuppuswamy scale. Total
family members- 4.
 The child has two siblings, both healthy and active, going to school.
9 yrs 7 yrs 5 yrs

11. Summary
 A 9 year old boy, with previous history suggestive of rheumatic
fever, advised monthly injections since the last 3 years which
were discontinued the past 1 year, presented with cough,
breathlessness, palpitations, along with fever and fleeting type of
joint pain and swelling of knee, ankle and elbow joint since past
15 days.
 Probable diagnosis
 Recurrence of rheumatic fever with rheumatic carditis.

12. PHYSICAL EXAMINATION

13. GENERAL PHYSICAL
EXAMINATION
Patient is conscious, cooperative, well
oriented with time, place and person
1. Pallor present
2. No Icterus, Clubbing, Cyanosis,
Lymphadenopathy or Edema

14.  Signs of Infective endocarditis: Absent(except
pallor)
 Head to toe examination:
Sunken eyes
Thyroid- normal.
Spine- normal.
No skeletal deformities.

15. Anthropometry:
1. Height: 126cm
Inference: Normal (Between 10th and 25th centiles)
2. Weight: 18.5kg
Inference: Below the 3rd centile.
BMI=12.85Kg/m2
Impression:UNDERWEIGHT
3.Arm span:125cm.
4.US:LS=1:1

16. Vitals:
1. BP:90/60mmHg Right arm supine position.
2. Pulse: 120bpm, Increased rate, regular rhythm, normal
volume & character. No radioradial or radiofemoral delay.All
peripheral pulses felt.
3. Respiratory rate: 30 cycles/minute. Abdominothoracic.
4. Temperature: 37.2°C
5. JVP: Not raised.

17. Cardiovascular system

18.  Inspection:
 Precordium appears normal.
 Apical impulse: diffuse, Left 6th ICS 1cm lateral to MCL.
 Visible pulsation seen in Left 2nd ,3rd,4th ICS.
 No visible epigastric pulsations.
 No scars, sinuses or dilated veins.
 Palpation:
 Apex beat is in Left 6th ICS 1cm lateral to MCL,
Hyperdynamic in character, Systolic thrill present.
 Parasternal heave present.
 Palpable P2.
 No epigastric pulsations.
 No carotid thrill.
 No palpable pericardial rub/tracheal tug.

19.  Percussion:
 Right heart border corresponds to sternum, Left
heart border corresponds to the apex.
 Auscultation:
 Mitral area:
S1normal, S2 muffled.
A high pitched, pansystolic murmur of grade IV
intensity,soft blowing in character,heard with the
diaphragm of stethoscope, in left lateral position
of the patient and at the height of
expiration.The murmur is radiated to the left
axilla and the back.

20.  Pulmonary area:
S1 heard, loud P2,ejection systolic murmur of grade III
intensity heard.
 Aortic area:
S1 S2 heard.
 Tricuspid area:S1 S2 heard. Pansystolic murmur of gradeIII
intensity.
 No carotid bruit.

21. Respiratory system
 Inspection:
Upper respiratory tract: normal
Lower respiratory tract:
Trachea central
Movements B/L symmetrical
No signs of volume loss.
No scars, sinuses or dilated veins

22.  Palpation:
Trachea central
Movements B/L symmetrical
Vocal fremitus: B/L equal
 Percussion: Normal resonant note B/L
 Auscultation: Normal vesicular breath sounds heard in
all areas. No added sounds.

23. Gastrointestinal system
 Oral cavity:Normal
 Per Abdomen:
Soft, nontender
Liver is palpable 2cm below the RCM.
Liver span 8cm.
Spleen not palpable.
No shifting dullness.
Traube’s space tympanic on percussion.
Normal bowel sounds heard

24. 1. Nervous system examination:
 Higher mental functions: No abnormalities detected
 No cranial nerve abnormalities
 Motor system: No abnormalities detected; Bilateral
flexor plantar
 Sensory system: No abnormalities detected
 Stance and Gait: No abnormalities detected
 Co-ordination: No abnormalities detected
 Signs of meningeal irritation: Absent
 Skull and spine: No abnormalities detected

25. Summary
A 9 yr old child with dyspnoea,on& off fever,cough, chest
pain,palpitation since the past10days.
O/E: Found to have tachycardia, pallor, apex is shifted
outwards & is hyperdynamic, systolic thrill at the
apex, parasternal heave, palpable P2, pansystolic
murmur (grade IV)in mitral area radiated to the
left axilla and the back. loud P2

26. Diagnosis
 ACUTE RHEUMATIC CARDITIS WITH MITRAL
REGURGITATION WITH FEATURES OF
PULMONARY HYPERTENSION.
PATIENT IS IN SINUS RHYTHM AT PRESESNT
NOT IN CCF OR INFECTIVE ENDOCRDITIS.

27. Investigation

28.  Complete blood counts:
 1. Total count: increased
 2. Differential count: polymorphonuclear leucocytosis
 3. Hb: anemia
 4. Peripheral smear
 5. ESR:
 Raised: acute rheumatic fever
 Decreased: CCF, mild carditis, chorea
 6. Acute phase reactants:
 ESR: increased
 CRP: increased (beta-globulin in a/c rheumatic fever)
 7. Blood culture
 Liver Function Tests
 Renal Function Tests
 Urinalysis
 ABG

29.  Evidence of streptococcal infection
 1. ASO titer
 2. Other antibodies:
 Antihyaluronidase (AH)
 Anti-streptokinase (ASK)
 Antistreptozyme (ASTZ)
 Anti-DNAse B
 3. Positive throat culture
 4. Rapid streptococcal antigen detection test
 Evidence of carditis
 1. CXR
 2. ECG
 3. ECHO

30. Investigations Results Inference
Hemoglobin 9.5 g% Moderate anemia
Total Count 15,800 cells/cumm Elevated
Differential Count N70, L17, M1.3 Normal
ESR 13mm/L/hr ??? Normal
Platelets 3.79lakhs Normal
Serum urea 22mg/dl Normal
Serum Creatinine 1.5mg/dl Raised
Na+ 131mEq/L Slightly low
K+ 4.4mEq/L Normal
Cl- 93.3mEq/L Slightly low
HCO3- 17.5mEq/L Low
Ca2+ 8.6mg/dl Normal
Phosphate 4.2mg/dl Normal

31. Investigation Result Inference
Total bilirubin 0.6g/dl Normal
Direct bilirubin 0.17g/dl Normal
Serum globulin 3.7g/dl Slightly elevated
SGOT/AST 29IU/L Normal
SPGT/ALT 30IU/L Normal
ALP 215IU.L Normal
Urinanalysis Albumin: 2+ Albuminuria
2-4 pus cells Normal
8-10 RBCs Elevated
pH 7.45 Normal
pCO2 28.2 Low
pO2 187 High
SpO2 99.7% Normal
HCO3- 19.3 Low

32.  Peripheral smear:
 Blood culture:
 Negative
 CXR:
 Cardiomegaly present
 No signs of pulmonary congestion
 ECHO:
 Rheumatic heart disease
 Mildly dilated LA/LV
 Severe mitral regurgitation
 Mild pericardial effusion
 No pulmonary arterial hypertension
 No vegetation

33. Impression
 Acute rheumatic carditis with severe MR, cardiomegaly &
mild pericardial effusion
 Anemia
 Respiratory alkalosis - compensated (low pCO2, low HCO3-
and normal pH)

34. Management
Management

35. Management of Acute Episode
 Bed Rest
 For carditis and arthritis
Prednisolone 2 mg/kg/day for 2 weeks
Taper over next 2-4 weeks
Start Aspirin 50-75 mg/kg/day simultaneously
to complete total 12 weeks
 Antistreptococcal therapy
200,000 units/ kg/ day for 10 days

36. Infective Endocarditis
 Based on culture and sensitivity
 Empirical Therapy : Add aminoglycoside

37. Secondary Prophylaxis
 Up to 40 years of age or Lifelong
Benzathine Penicillin 0.6 MU single dose every 15 days

38. Management Of Malnutrition And
Anemia
 Health Education – non compliance!!
 Increase Calorie intake
 Increase frequency
 Vitamins
 Oral Iron – 3-6 mg/kg/day. Continue for 4-6 months
after correction
 Dietary counseling

39. Current Medications
 Inj. Crystalline Penicillin 1 MU IV 6 hourly
 Inj. Furosemide 20 mg IV BD
 Inj. Ranitidine 20 mg IV 8 hourly
 Tab. Paracetamol 500 mg (1/2) SOS
 Inj. Gentamicin 60 mg IV OD (3 mg/kg/day)
 Inj. Digoxin
 Tab. Prednisolone 10 mg 6 hourly
 Neb. Asthalin 1 respule 4 hourly

40. Atrial Fibrillation
 Rate Control – Digoxin
 Rhythm Control – Amiodarone
 Anticoagulants

41. THANK YOU!