A case of an 11 year old male who presented in heart failure after a series of strep throat infections and an unconfirmed history of rheumatic fever.

1. THE UNIVERSITY OF ZAMBIA
SCHOOL OF MEDICINE
Milton Hamaamba 7th year
Mbao Njobvu 5th year
Yvette Maseka 5th year
Moderator; Dr Mwenechanya-Paediatrician UTH

2. 
 YVETTE MASEKA – 5th YEAR
Presenter:

3. 
 Name: AM
 Age:11yrs old
 Tribe: shona
 Religion: shona
 Residence:kabwe
 Informants:mother and father
 Languange used: english
 Date of interview: 7th february 2019
 Self referral
demographics

4. 
 Worsening chest pain X12/12
 Difficulties breathing X 7/12
Chief complaint

5. 
 The patient has had a long standing history of chest
pain for about a year now, which was of gradual
onset , stabbing in nature, radiating from the left to
the right side of the chest and has been
progressively worsening, no known relieving or
exacerbating factors and is not associated with
inspiration.
The pain is associated with difficulties in breathing which
started about 7 months ago.
HOPC

6. 
The difficulties in breathing had a gradual onset, was
only there when walking long distances ,not associated
with time of day but progressed to failure to lie flat and
waking up at night to catch a breath at night. However
was not associated with cough, noisy breathing or time of
day

7. 
 H/O awareness of heartbeat , easy fatiguability and
dizziness.
 No H/O swelling of feet
 H/O weight loss, fever with no chills ,no drenching
night sweats
 No trauma

8. 
CVS,RS as in HOPC
 GIT
No abdominal distension or pain, diarrhoea
,constipation, or abnormal stool colour
nausea, vomiting or loss of appetite
 MSS
No rash, joint pain or swelling, bluish discolouration of
skin ,yellowing of eyes or skin
ROS

9. 
 CNS
No h/o fainting, fitting, abnormal
movements,headache or blurred vision
 GUT
h/o frequency, no h/o urgency, pain or blood in urine

10. 
 2nd admission with no h/o of admissions in infancy
 Has had no similar presentation but has h/o swollen left
ankle joint x1/12 in 2017
 Multiple sore throats the last one being in Aug. 2017
 first admission was at Kabwe general hospital for chest
pain and an xray showing fluid around the heart
(pericardial effusion) in jan 2018
 RVD-NR, No history of TB or TB contact, SCD, Asthma,
DM, or BT
 No hx surgery
PAST MEDICAL HX

11. 

12. 
 Benzathine penicillin
 Paracetamol
 Folic acid
 Ferrous sulphate
 Gentamycin and x-pen
DRUG HX

13. 
 Currently on:
Frusemide
Digoxin
Enalapril

14. 
 Born via SVD @ term with a bwt of 4.5 kg at chibwe
clinic in kbw, no antenatal, intrapartum or postnatal
complications
BIRTH HX

15. 
 Smile : 4months
 Head support: 6months
 Sit :8months
 Stand:14months
 Talking: I yr 8months
 growing at the same rate as other siblings with no
developmental delays
DEV HX

16. 
 Under five card not seen but said to be fully
immunised
Immunisation hx

17. 
 Weaned at 8 months ,porridge with groundnuts was
introduced,portions not known
 Current feeds: has 3 meals a day usually eats nshima
with goat meat, chicken ,beans or chibwabwa
Feeding hx

18. 
 2nd born in a family of 6,with all siblings alive and
well. informants not sure of other siblings ages.
 No hx of similar presentation, cardiac disease,
asthma, SCD, HTN ,DM
 No hx of consanguinity
Family hx

19. 
 Parents are large scale farmers
 6 roomed house,8 occupants
 Outdoor pit latrine
 source of water borehole(chlorinated)
 House is covered by a wall fence and is not located
near the mine area.
Social hx

20. 
 Stopped going to school 7 months ago due to
breathing difficulties and chest pain, he was in
grade 4 with a fair performance and he interacts well
with friends
Personal hx

21. 
 Presenting AM m/11yrs who presented with chest
pain, dyspnoea, orthopnoea, PND, with symptoms
of anaemia and h/o fever, sore throat, joint pain and
pericardial effusion. however no h/o cough ,
oedema, night sweats.
Summary..

22. 
 Anaemia with Left Sided Heart Failure (NYHC
II)secondary to Rheumatic Heart Disease
DDX
 Infective endocarditis
 TB pericarditis
impression

23. 
 MBAO NDJOBVU – 5th YEAR
Presenter:

24. 
General examination
 I examined a school going male child propped up
in bed who was fully conscious, in mild respiratory
distress with slight nasal flaring, ill looking with
mild wasting orientated to time place and person
and completely cooperative. He was afebril and
there was no lymphadenopathy. He was mildly Pale
with no Jaundice and no central cyanosis.
Physical examination

25. 
VITALS
 RR :37
 Pulse- 72 Bpm palpable regular and full volume
 BP: 110/60
 O2 saturation: 97%
 Temp 35.0 Degrees celcius
 ANTHROPOMETRY
 Height – 144cm (height for age above median)
 Weight- 29.9kg
 BMI- 14.1kg/m2 under weight(below 5th percentile BMI for age )

26. 
 CVS
There was no peripheral cyanosis, no finger clubbing
no osler nodes no janeway lesions, no koilonychia.
Radial pulses were palpable, full volume, regular and
there was radial-radial syncronicity, no collapsing
pulse,brachial pulses were palpable regular and full
volume .
No angular cheilitis, no signs of glositis.
There was no jugular venous distention. No carotid
bruits and JVP was 3cm.

27. 
There was normal overlaying skin and precordium was
hyperactive.
There were no palpable thrills and apex beat was
palpable at left 6th intercostal space 2cm medial to the
anterior-axillary line.
S1 S2 heard with a high pitched murmur throughout
systole which was loudest around the mitral area and
radiating towards the axilla.
No basal crepitations.
No hepatojugular reflux.
Palpable femoral, popliteal and dorsalis pedis pulses
No pedal oedema

28. 
 RESPIRATORY SYSTEM
The Chest was symmetrical, with equal chest expansion
Trachea centrally located, equal tactile fremitus,
resonant percussion note in all lung fields.
Vesicular sounds breath sounds in all lung fields heard
on auscultaion with no added sounds

29. 
 PER ABDOMENN
Normal overlaying skin , no abdominal distension.
Abdomen was moving with respiration.
Bowel sounds were heard.
Soft, non-tender , no palpable masses and no
organomegally.

30. 
 CNS
 The patient was fully conscious, cooperative, able to
talk and ask questions, cranial nerves were intact.

31. 
 MSS
No rashes , no joint swelling and tenderness.
Full range of motion in all joints. Muscle power 5/5 in
all flexor muscles

32. 
Leukocytes –neg
urobilinogen-neg
Protein-neg
PH-5
Blood –neg
SG -1.005
Ketones –neg
Bilirubin –neg
Glucose -neg
urinalysis

33. 
SUMMARY
I examined a school going child propped up, fully
conscious, ill looking with mild wasting and pallor.
Patient had a displaced apex beat with a grade 3 pan
systolic murmur radiating to the left axilla. However
the patient had no stigmata for infective endocarditis
and no pedal oedema.

34. 
 Anaemia with Left Sided Heart Failure (NYHC II) in
a patient with mitral regurgitation secondary to
RHD
Ddx
 Dilated cardiomyopathy
 TB pericarditis
Impression..

35. 
 MILTON HAMAAMBA – 7th YEAR
Presenter:

36. 
 LABORATORY
• FBC/DC, Retic. count
• Peripheral smear
• ESR, CRP
• U & Es, Cr
• LFTs
 IMAGING
• Echo
• ECG
• CXR
Investigations

37. 

38. 

39. 
 General Measures
• Bed rest
• Oxygen
• Cardiac position
• Adequate feeds
• Limit salt and fluid intake
• Pharmacological therapy
• Surgery
Treatment

40. 
 Reduce preload
 Enhance cardiac contractility
 Reduce afterload
 Supportive treatment
 Prophylaxis
Pharmacological
therapy

41. 
 Diuretics
• Furosemide 1-2 mg/kg/day I.V
• Spironolactone 2-3 mg/Kg/day P.O
• Clorthiazide 20-40 mg/Kg/day P.O
Preload reduction

42. 
 Ionotropics
• Digoxin 0.005 mg/Kg/dose P.O divided into 2 doses
Or
• Dopamine 5-10 mcg/Kg/min I.V
Enhancing Cardiac
Contractility

43. 
 ACE Inhibitors
• Captopril 0.3-6 mg/Kg/day BD or TDS
• Enalapril 0.08 mg/Kg/day P.O or 0.01-0.02
mg/Kg/day divided in 2 doses.
Reduce afterload

44. 
 Anaemia- correct by giving Ferrous sulphate and
Folic acid.
BT only when patient is out of heart failure.
 Deworming- Mebendazole 500mg P.O
 Nutrition – encourage frequent feeds
Supportive Treatment

45. 
 Secondary Prophylaxis.
• Benzathine penicillin 1.2 Munits given every 4 or 3
weeks.
Prophylaxis

46. 
 Annuloplasty or valve replacement can be done at
the age of 21years.
Surgery

47. 
Thank you