A 14-year-old boy presented with difficulty breathing, facial swelling, swelling of both feet, and chest pain for two days. He had a history of a similar episode 8 months prior where he was diagnosed with a heart condition. On examination, he had an irregularly irregular pulse, low blood pressure, visible apex beat, and grade V pansystolic murmurs in the mitral, tricuspid, and pulmonary areas, suggestive of chronic rheumatic heart disease with mitral regurgitation and left ventricular hypertrophy.

1. Case presentation
Dr Sameen Ehtesham
JRA 2 pediatrics

2. • I am presenting the case of Master Sumit Oraon , 14 year old
male child s/o Mr Birsu Oraon , a product of non-
consanguinous marriage , resident of Gumla , Jharkhand ,
was admitted to this hospital on 16/6/22 and examined by
me on 26/6/22.
• Informants are mother and elder sister who are reliable.

3. Chief complaints
• Difficulty in breathing
• Facial puffiness and swelling of both feet
• Chest pain for 2 days

4. History of Present illness
• My patient was apparently asymptomatic 2 days back when
he developed puffiness around both eyes and swelling of
both feet which was insidious in onset , persisted
throughout the day , non-progressive , not associated with
any aggravating or relieving factors.
• There is also history of difficulty in breathing which was
insidious in onset and increased in severity over 2 days , was
present even at rest and aggravated by regular activities like
walking .

5. • There was also c/o pain in left side of chest which was
sudden in onset , severe in intensity , continuous , non –
progressive , radiating to left axilla and shoulder , associated
with palpitations , not associated with any aggravating or
relieving factors.

6. • History of fever 1 day back which was low grade, resolved
spontaneously without any medications.
• History of cough for last 1 day which was dry in nature ,
intermittent , aggravated on lying down.

7. No h/o :
• Hemoptysis
• Dizziness ,Syncope, abnormal body movements.
• Joint pain
• Bluish discoloration
• Decreased urination
• Excessive sweating over forehead.
• Sleep disturbances
• Rashes , hematuria

8. Past history
• The patient had similar complaints alongwith generalized body pain 8
months back for which he was admitted to RIMS .
• He was diagnosed with a heart disease and was treated with oral as
well as injectable drugs.
• Patient was admitted for 2 weeks and then discharged on oral
medications and asked to follow up after 2 weeks.
• There is no H/o hospitalization before this but the mother gave
history of visible pulsations over left side of chest for last 2 years.

9. Treatment history
• Patient was on regular followup in cardiology department at
RIMS and was taking some oral medications.
• His symptoms were relieved to a great extent by these
medications.

10. Contact history
• No H/O contact with TB/Covid patient.

11. • Antenatal , natal and postnatal period were uneventful.
• Development History : achieved normal developmental
milestones as per age.
• Immunization history : immunized as per national
immunization schedule.

12. Dietary history
• Patient has a vegetarian diet with 3 major meals.
• Total calorie requirement:1760 kcal/d
• Total calorie intake :1120kcal
• Deficit:640kcal
• Total protein requirement:54g/d
• Total protein intake:45g
• Deficit :9g

13. Personal history
• Patient was studying in 8th grade but has not being going to
school since last November.
• Has a healthy relationship with his friends and family
members.
• Normal sleep pattern with regular bladder and bowel habits .

14. Family history
• His family comprises of 5 members with parents , 1 older
sister and 1 younger brother.
• There is no H/O similar illness in the family.
• No H/O diabetes , hypertension or any other chronic illness
in the family.

15. Socio-economic history
• His father is uneducated , works as a farmer and is the only
earning member of the family.
• Family lives in a kachha house with 5 rooms but no sanitary
facilities.
• They drink water from well.
• According to modified Kuppuswamy Scale , family belongs to
lower socioeconomic class.

16. Examination :
• Patient was examined on day 13 of illness and day 11 of
hospital stay.
• My patient is conscious, co-operative and well oriented to
time , place and person , sitting comfortably on chair with
arms on the side.

17. Vitals
• Pulse rate : 62/min , all the peripheral pulses are felt ,
irregularly irregular in rhythm, low in volume, normal in
character .
• There is no radio-radial or radio-femoral delay . Condition of
arterial wall is normal.
• RR: 20/min , abdomino-thoracic type.
• BP: 104/58 mm Hg taken in left arm by auscultatory method
in supine position. ( 5th- 50th centile for his height and age ).

18. • Spo2 : 97% at room air
• Temperature: 98.5 F in left axilla measured by digital
thermometer.
• Anthropometry :
• Weight : 33 kg (<3rd percentile for age )
• Height : 152 cm (3rd-10th percentile for age)
• BMI : 14.28 (3rd-5th percentile for age )

19. General examination:
• Head is normal in shape, size and symmetry .
• No facial asymmetry , loss of nasolabial folds and ptosis.
• Eyes, ears and nose appear normal in shape and symmetry without any
discharge.
• Oral cavity appears normal with normal dentition.
• JVP is raised .
• Skin is normal in texture with few scarmarks on abdomen and knees .
• Hair is normal in texture .
• Hands , feet and limbs appear normal.
• There is no pallor, icterus, cyanosis, clubbing , lymphadenopathy and
edema.

20. CVS examination:
• Inspection :
• Chest is bilaterally symmetrical .
• No bulging of precordium or intercostal spaces.
• Apex beat is visible in left 5th intercostal space lateral to mid-
clavicular line.
• No visible pulsations over suprasternal and epigastric region.
• No dilated veins seen over the chest and back.

21. • Palpation:
• Mitral area : Apex beat palpated over left 5th intercostal
space lateral to mid clavicular line , hyperkinetic in character
. Systolic thrill felt.
• Tricuspid area: Grade 3 parasternal heave present alongwith
thrill.
• Pulmonary area: no pulsations or thrill felt.
• Aortic area : no pulsations or thrill felt.

22. Auscultation :
• Mitral area : S1 normally audible,S2 not audible , irregular in
rhythm. Grade V pansystolic murmur heard radiating to left axilla
and back , heard best with diaphragm of stethoscope , best heard
in expiration.
• Tricuspid area : s1 normally audible, s2 not audible, grade IV
pansystolic murmur present
• Pulmonary area : : s1 normally audible, s2 not audible, grade IV
pansystolic murmur present
• Aortic area : S1 and S2 normally audible. No murmur present.

23. • Respiratory system : B/L air entry present and equal . No
added breath sounds heard.
• Per abdomen: Abdomen appears normal without any
distension. Liver palpable upto 3 cm below the costal margin
in mid clavicular line , firm in consistency , regular margins ,
smooth surface , tender with liver span of . No splenomegaly.
B/L kidneys not palpable.
• CNS examination was within normal limits.

24. Case summary
• Master Sumit Oraon , 15 year old male child from Gumla , Jharkhand
presented with complaints of difficulty in breathing , left sided chest
pain, facial puffiness and B/L pedal edema with past history of heart
disease diagnosed 8 months back .
• On examination , patient was stunted and underweight with
irregularly irregular rhythm , hypotension , visible apex beat and
grade V pansystolic murmur in mitral , tricuspid and pulmonary area .
• Based on history and clinical examination , patient appears to be a
case of chronic heart disease , most probably rheumatic heart disease
with mitral regurgitation and left ventricular hypertrophy.

25. THANK YOU