BRIEF HISTORY
An 18-year-old girl was admitted through out-patient department with six hours history of severe left sided chest pain. For the last four months, she had increasing shortness of breath and fatigue on exertion with swelling of her ankles. During the last four hours of her chest pain, her breathlessness had worsened. There was no history of haemoptysis. She had mild unproductive cough for the last three months. The chest pain was described as sharp with no radiation and was worse on deep breathing. She had been given frusemide 40 mg daily for her swollen legs and had also been started on digoxin 0.25 mg once a day a week before her admission. Her doctor had given her pethidine 50 mg parenterally before sending her to the hospital, but this had failed to control her pain. She had
no known drug allergies. She could remember having frequent sore throats as a child, but there was no clear history of joint pains. One of her brothers, however, had a heart condition and had been treated with medicines for a long time.
IMPORTANT CLUES ON CLINICAL EXAMINATION
On examination, she was very dyspnoeic and had central cyanosis. She was apyrexial. JVP was raised by 4 cm. There was moderate pitting oedema over her both legs. Her throat was normal. Blood
pressure was 120/70 mm Hg. There was no clubbing or lymphadenopathy. Clinically she was euthyroid. Her pulse was 110 per minute and irregularly irregular. Peripheral pulses were palpable. Apex beat was tapping in character and she had a left parasternal heave. The first heart sound was loud and she had a rough, rumbling, mid-diastolic murmur localized to the apex.
Opening snap followed closely on the second heart sound. She had bilateral basal crackles with dullness and diminished air entry at her left base. There was no pleural rub. Liver was 4 cm enlarged,
smooth and tender. There was no splenomegaly or ascites. Fundi were normal and there were no localizing neurological signs.
INVESTIGATIONS
The following results of the initial investigations were available:
QUESTIONS
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Q.1. What is the most likely diagnosis and what complication
has occurred?
Q.2. What further four investigations will help the diagnosis?
Q.3. Give six important steps in the management of this patient.
Q.4. What criteria is applied to this disease?
Medicine
A.1.
The most likely diagnosis in this young girl with four months history of increasing fatigue, shortness of breath,
swelling of ankles with previous history of repeated sore throats and characteristic findings of mitral stenosis,is rheumatic heart disease. Sudden sharp pleuritic chest pain in a girl with mitral stenosis and atrial fibrillation strongly supports the diagnosis of pulmonary embolism. Systemic or pulmonary embolism is a common complication of atrial fibrillation. A pleural rub is not always present and may sometimes be difficult to detect in the presence of diffuse crackles and/or effusion.
A.2.
A.3.
A.4.
This includes major and minor criteria called Duckitt Jone’s
criteria.
The major criteria:
The minor criteria:
Two major and one minor or one major and two minor criteria are required to diagnose rheumatic fever.
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