2. Mrs. Rita Das, 48 yrs,housewife
From Gangapur, Cachar
C/O
1.Gradually increasing breathlessness – 2 yrs
2.Palpitaion -1 yr
3.Chest pain- 1 month
4.Cough -1 month
o Breathlessness was gradually progressive with initially being
exertional now the patient is orthopnic (NYHA Grade IV)
and is non seasonal.
o H/O PND present
3. o She was also complaining of palpitation for an year and she
noticed it first while lifting some heavy objects. They were
fast, paroxysmal, irregular, distressful and often increases
on activity.
o Palpitation increases the dyspnea and chest pain.
o She had given a history of sudden onset constricting
retrosternal chest pain, intermittent in type and which
usually get relieved with rest.
o There is H/O cough with scanty sputum production without
any H/O haemoptysis.
4. No H/O syncope, fever ,squatting,pain in legs during walking
, hoarseness of voice, dysphagia or any neurodeficit.
No recent h/o joint pain.
She was neither hypertensive nor diabetic.
No h/o iv drug abuse.
No h/o contacty to tuberculosis or high risk sexual
behaviour.
Uneventfull history of childbirth 25 yrs back.
No history suggestive of rheumatic fever in childhood.
5. EXAMINATION
Patient was conscious, oriented and cooperative.
Tachypnea was present with cold extremities.
Prefers to sit, pulse was 86/ min and irregularly irregular in
rhythm, low volume with a pulse deficit of 12 beats/ min.
Blood pressure was 108/80 mm of Hg and 118/82 mm of Hg
in upper and lower limbs.
Neck veins were engorged and pulsatile with absent
“a Wave”, respiratory rate was 23/ min and pattern was
thoraco-abdominal in type.
6. Oedema was present.
No pallor, cyanosis, icterus, clubbing and petechial rashes
were present.
On Systemic examination
CVS :
Heart rate of 98/min and irregular. Apex palpable at left 5th
intercoastal space outside midclavicular line, diffuse and
forcefull.
A diastolic thrill was palpable at apex.
Grade 2 Parasternal heave was present.
S1 was loud and variable and loud P2 heard over
pulmonary area with narrow splitting S2 and no LV and RV
S3.
On auscultation, a Grade 4 mid- diastolic murmur at apex.
opening snap present and no pre-systolic accentuation.
7. There was an associated Grade 3 pan-systolic blowing
murmur.
The intensity of systolic murmur increases on hand grip
and intensity decreases on expiration.
Intensity of both the murmurs increases on expiration.
Examination of the chest fine inspiratory basal
crepitations
Examination of abdomen reveals hepatomegaly.
Examination of CNS –WNL.
8. Provisional Diagnosis :
Rheumatic Heart Disease with Mitral Stenosis and
Mitral Regurgitation(MS>MR) along with features of
Pulmonary Hypertension and Congestive Heart
Failure(NYHA grade IV) with Atrial Fibrillation withot
any evidence of infective endocarditis and systemic
embolisation.
16. WHY SELECT A CASE OF RHD ?
Why select a case of RHD for presentation in such a elite
gathering of Cardiologist in 2015.
Is it
“Why throw away a needful day”
-- William Wordsworth, 1803
17. WHY SELECT A CASE OF RHD ?
Bedside Cardiology is a Dying Art almost buried under the
Gadgets of modern equipments and technology.
“ let us revive it and nurture it- lest we cease to be
clinician”
RHD is fading out rapidly and not as common today as the date
of my birth. RHD is buried under the heaps of CAD and its
phenotypes. However, it is not as uncommon in the developing
countries as it is thought.
Let us explore this and take steps to prevent it for it is avertable
and preventable only if clinicians are aware of it.
