Transcript
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 dayspalpitations since 15 daysFever , on and off since 15 daysJoint 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 downNo diurnal variation.No seasonal variationNot associated with bluish discoloration of skin or squatting
episodesBreathlesness is associated with cough
Cough associated with scanty mucoid expectoration since the
past 15 dyas, non blood stained.Not associated with rise in temperatureNot associated with wheezeNo 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.
PalpitationsPresent even at rest.Not associated with chest painAssociated with dizziness but there was no loss of
consciousness.
FeverHigh gradePresent on and off since 15 daysNot associated with rigors
Pain and swelling of the left knee joint since 15 daysAssociated with limitation of movement, the child could not
walk due to the painNot history of traumaafter 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
Negative historyno history of reduced urine outputno history of pedal oedemaNo history of abdominal painNo 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
PAST HISTORYHistory 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
BIRTH HISTORYNo complications in the antenatal periodInstitutional delivery at term, normal vaginal
delivery, baby cried immediately. Birth weight- not known.No complications during the deliveryNo post natal complications. NO ICU
admissions after birth.No problems during infancy.
DEVELOPMENTAL HISTORYall milestones were achieved on time.
IMMUNISATION HISTORYImmunisation up to dateOPV, BCG, DPT and boosters , Measles vaccine
given.
DIET HISTORY
MEAL FOOD ITEM CALORIES PROTEIN
Morning 1 cup milk with sugar2 biscuits
127 4.1
Breakfast 2 dosa , half cup dal
200 6
Lunch 1 cup rice1 cup sambar1 cup of vegetables
376 10
Evening snack 1 cup milk with sugar
87 3.3
dinner 2 rotiHalf cup dal1 fish
287 24
Calories requirement = 1620 kcalCalories obtained= 1047Defecit= 573
Protein requiremnt=33.2 g/dayObtained= 35 gNo defecit
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.
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
SummaryA 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 diagnosisRecurrence of rheumatic fever with rheumatic
carditis.
PHYSICAL EXAMINATION
Patient is conscious, cooperative, well oriented with time, place and person
1. Pallor present2. No Icterus, Clubbing, Cyanosis,
Lymphadenopathy or Edema
GENERAL PHYSICAL EXAMINATION
Signs of Infective endocarditis: Absent(except pallor)
Head to toe examination: Sunken eyes Thyroid- normal. Spine- normal. No skeletal deformities.
Anthropometry:1. Height: 126cmInference: Normal (Between 10th and 25th centiles)2. Weight: 18.5kg Inference: Below the 3rd centile.
BMI=12.85Kg/m2Impression:UNDERWEIGHT3.Arm span:125cm.4.US:LS=1:1
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°C5. JVP: Not raised.
Cardiovascular system
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.
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.
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.
Respiratory systemInspection: Upper respiratory tract: normal Lower respiratory tract: Trachea central Movements B/L symmetrical No signs of volume loss. No scars, sinuses or dilated veins
Palpation: Trachea central Movements B/L symmetrical Vocal fremitus: B/L equalPercussion: Normal resonant note B/LAuscultation: Normal vesicular breath
sounds heard in all areas. No added sounds.
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
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
SummaryA 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
DiagnosisACUTE RHEUMATIC CARDITIS WITH
MITRAL REGURGITATION WITH FEATURES OF PULMONARY HYPERTENSION.
PATIENT IS IN SINUS RHYTHM AT PRESESNT
NOT IN CCF OR INFECTIVE ENDOCRDITIS.
Investigation
Complete blood counts:1. Total count: increased2. Differential count: polymorphonuclear
leucocytosis3. Hb: anemia4. Peripheral smear5. ESR:
Raised: acute rheumatic feverDecreased: CCF, mild carditis, chorea
6. Acute phase reactants:ESR: increasedCRP: increased (beta-globulin in a/c rheumatic fever)
7. Blood cultureLiver Function TestsRenal Function TestsUrinalysisABG
Evidence of streptococcal infection1. ASO titer2. Other antibodies:
Antihyaluronidase (AH)Anti-streptokinase (ASK)Antistreptozyme (ASTZ)Anti-DNAse B
3. Positive throat culture4. Rapid streptococcal antigen detection test
Evidence of carditis1. CXR2. ECG3. ECHO
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
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+2-4 pus cells8-10 RBCs
AlbuminuriaNormal
Elevated
pH 7.45 Normal
pCO2 28.2 Low
pO2 187 High
SpO2 99.7% Normal
HCO3- 19.3 Low
Peripheral smear:
Blood culture: Negative
CXR:Cardiomegaly presentNo signs of pulmonary congestion
ECHO:Rheumatic heart diseaseMildly dilated LA/LVSevere mitral regurgitationMild pericardial effusionNo pulmonary arterial hypertensionNo vegetation
ImpressionAcute rheumatic carditis with severe MR,
cardiomegaly & mild pericardial effusionAnemiaRespiratory alkalosis - compensated (low
pCO2, low HCO3- and normal pH)
Management
Management
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
Infective EndocarditisBased on culture and sensitivityEmpirical Therapy : Add aminoglycoside
Secondary ProphylaxisUp to 40 years of age or Lifelong
Benzathine Penicillin 0.6 MU single dose every 15 days
Management Of Malnutrition And Anemia
Health Education – non compliance!!Increase Calorie intake Increase frequencyVitaminsOral Iron – 3-6 mg/kg/day. Continue for 4-
6 months after correctionDietary counseling
Current MedicationsInj. Crystalline Penicillin 1 MU IV 6 hourlyInj. Furosemide 20 mg IV BDInj. Ranitidine 20 mg IV 8 hourlyTab. Paracetamol 500 mg (1/2) SOSInj. Gentamicin 60 mg IV OD (3
mg/kg/day)Inj. Digoxin Tab. Prednisolone 10 mg 6 hourlyNeb. Asthalin 1 respule 4 hourly
Atrial FibrillationRate Control – DigoxinRhythm Control – AmiodaroneAnticoagulants
THANK YOU!
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