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Case Study

Rheumatic Heart Disease-A Case Study
Dr Adil Chimthanawala

An 18yr female was brought to our hospital on 7/04/03. Her old reports diagnosed at PGI and Superspeciality Hospital Nagpur, as a case of Rheumatic Heart disease- MR (Severe) + AR (mod)+ PH.

She came with c/o -
1. Breathlessness (N.Y.H.A Gr III) < exertion, < sitting position and palpitations.
2. Chest pains-Sensation of constriction in the precordium, radiating to the back, > by slight massage on chest.
3. Cough with copious jelly- like expectoration. < lying down, night. No haemoptysis.
4. Swelling over the feet.
H/O Orthopnoea +. No H/O Paroxysmal Nocturnal Dyspnoea, Syncope, fever, joint pains, rashes, haematuria or convulsions. No Bowel or bladder complaints. All complaints were present since 3 years, but increased in intensity steadily since 7 days, after the patient picked up a bucketful of water. She was taken to a private physician who prescribed certain medications (Inj Lasix) and then referred to our hospital.

O/E GC not satisfactory. Conscious,
Thin built, Short stature, afebrile
Pulse-reg 120/min, good vol, mildly
collapsing, Resp Rate-28 /min,
BP -100/60mmHg,
Pallor+. No Icterus. Cyanosis or Clubbing.
Tongue clean and moist. Throat- mild congestion +
Signs of CCF+-JVP raised, Edema feet +
Skin-no rheumatic nodules/rashes.
Spine-mild scoliosis +. Joints normal and mobile
P/A-liver/ spleen-not palpable. No evidence of free fluid in abdomen.
Sounds in all 4 quads +.
CVS-Precordium bulging, Apex beat-left 6th intercostal space. palpable P2 and thrill at apex, dancing carotids +. no parasternal heave.
HS 1- muffled, P2- loud, S3 gallop +.
Pan-systolic murmur at apex, crescendo-decrescendo, gr V, radiating to back Ejection diastolic murmur at A2, Gr III increased on breath held in expiration.
RS-Trachea central, Air entry - decreased at bases, billateral coarse crepts+.

7/4/03 Blood sent for investigations
POP and O2 inhalation @ 2L/min
7.10pm Adv ECG, X-ray Chest PA, ECHO/Doppler. Stroph Q 10dr 2hrly
10.10pm Hb-9.6gm%, TLC-10,200/cu mm, P-70%, L-28%, E-2%, Rx ct all
ESR-30mm, B. Urea- 42mg %, S. Creat- 1.3 mg %,
S. Na-140mEq/l, S.K- 3.5mEq/l, T. Prot-7.2 gm%, S. Alb-2.4gm%, S. Bil-0.6 gm% , S.AST-44 U/L,
S.ALT- 36 U/L, CRP-+ve.
X-Ray Chest PA-Cardiomegaly +, Increased Bronchovascular markings bilaterally/L
USG abd-WNL,
ECG-HR 120/m, NSR, axis-45deg, P 0.08sec,
PR 0.12 sec, QRS 0.06 sec, Global T inv, LVH +.
2D ECHO. Both MV Leaflets mod thick. No subvalvular crowding or calcification, MV valve non stenotic shows III/IV MR. Aortic Leaflet thickened. Aortic valve complete.
Doppler shows Gr III/IV AR. Tricuspid/ Pulm valves normal LA/LV dilated. Other cardiac chambers normal in dimensions.
No Pericardial effusion, Fair LV systolic and diastolic func, LVEF-50%, No intracardiac clot/mass.
8/4/03 Pt.dyspoenic and uncomfortable. P-130/m, reg, Omit Strophanthus
8 am R-24/m,BP- 90/60 mmHg, pallor +, Laurocerasus Q 10dr 2h
S/o CCF+ RS-bil coarse crepts + POP/O2 inhalation
CVS-HS 1- muffled, P2- loud, No S3 gallop.
PSM at apex, EDM at A2, CNS/Abd NAD
4 pm Dyspnoea less. Urine output 1100cc, since adm ct. all
Vitals stable. Systemic same.
ECG- HR 100/m,NSR, axis -40deg, P/PR/QRS N,
Global T inv, LVH +
9.10pm Pt. much better. ASO titre 110 TU O2 SOS
Laurocerasus Q 2h
9/4/03 Pt slept well, Dyspnoea less, cough/expect ++, Lauro Q 10 dr 4h
8.30 am Passed stool. Urine N, No chest pain Light diet.
P 96/m, R 20/m, BP-110/60 mmHg,
Pallor ++, S/o CCF+ edema feet decreased
RS- bilateral fine crepts+
CVS-HS 1-muffled, P2- loud, No S3 gallop.
PSM at apex, EDM at A2, CNS/Abd NAD
7.30pm Mobilized. Urine N, No chest pain Lauro Q 10 dr BD.
P 90/m, R 20/m, BP-110/70 mmHg, Rest ct all.
Edema feet less, RS-bilateral fine crepts+
CVS-HS 1-muffled, P2-loud, No S3 gallop.
10/4/03 Pt.feeling better. No Dyspnoea reduced. Lauro Q 10 dr BD
Cough with expectoration +, vitals stable SL TDS
crepts reduced . ECG same
11/4/03 Pt.>, Dyspnoea/chest pain > Lauro Q 10 dr BD
Cough with expectoration persistent SL BD
No Crepts, Urine/stools/diet/sleep N
12/4/03 Pt. discharged on request. Lauro Q 10 dr BD
Adv. Medicines to be ct. SL BD
2/7/03 Pt. visited after Double valve replacement at SSH and PGI Nagpur.
On allopathic drugs/Inj Penidure every 21 days.
But not willing to ct allopathic injections.
Called for detailed interview after 1 week
9/7/03 Patient’s mother stated - "Sir, we are from a middle class family. My husband, my son, aged 15 years, daughter and me. My son too has got Rheumatic Heart disease. His Balloon Mitral Valvotomy was done 4 years ago. My husband is serving in a bank. My daughter is our first child and was detected to have RHD 3 years ago. She was on Inj Penidure and was advised surgery then. Since the last acute episode, we became very disturbed hence went in for surgery. Now, we wish that the Inj Penidure which she has been advised for life be discontinued. Also, she has other complaints too. She stopped schooling for lack of interest & concentration in studies and physical weakness. She is a very obstinate, sensitive girl and weeps on every little matter even at this age. She is basically restless and the continuos moving of feet really irritates us. Even after her surgery, she feels that she will never recover. Sir, she has menstrual troubles. Her menses are profuse, passes clots with intense abdominal pain and are offensive > lying on the stomach. She passes thin white discharge with itching over genitals." During the entire interview the patient hardly spoke.

·         Ambithermal

·         Appetite-Normal.

·         Desires salty foods, chilled drinks

·         Thirst-+++

·         Sweat-scanty

·         Urine/stool-normal. H/o Pinworms ++, scratches in the anal region at night.

·         Sleep-sound. Prefers sleeping in prone position.Dreams-not specific.

·         PSM at apex, EDM at A2, CNS/Abd NAD

Personal History -1st child of a non-consanguinous marriage. H/o severe anaemia in mother during pregnancy, Premature delivery at 36 wks with birth weight of 1.8kg was kept in an incubator for jaundice. Vaccinated till date. All milestones normal. Hobbies- loves music. In school - average student.
P/H-RHD + MR(Sev) + AR(mod)+ PH since 3 years.
Repeated hospitalizations for the same. On Inj Penidure and was Adviced surgery.
F/H-Brother-RHD: MS, PH (BMV done), Father - Urethral stricture (rec diltations), PGF-Renal stones, Rhematoid Arthritis(died), PA- RHD,

Medo 1m 3d. Sac lac BD x 1mth. Psychotherapy
Pt much better, Depression >>, SL 1 TDS x 1 mth. Sensitivity/obstinacy >>, Counseling done. Menses- 6 days ago. Avg flow. Dysmenorrhoea > Adv to resume studies. Leucorrhoea ++ thin serous discharge, itching+. No Chest pain, dyspnoea, Vitals stable. Chest clear. HS - valvular click at apex, ECG-WNL
No complaints. No depression. Sac lac ct. Confidence of pt good. Pt. started studies and was Re-admitted in 9th std. Menses 3/29 days, avg flow. No dysmenorrhoea. Leucorrhoea + >, No itching. Hb = 11 gm%, TLC-9,700/cu mm, P56%, L40%, E3%, M 1%, ECG-WNL. 2D ECHO-All valves normal. LV mildly dilated. Other cardiac chambers normal in dimensions. No Pericardial effusion, Good LV systolic and diastolic func, LVEF-65%, No intracardiac clot/mass/vegetations.
Pt still under follow-up. Improving. No complications of replaced valves reported.


1. Strophanthus-hisp Q
 was given as a short acting remedy for controlling the Left Ventricular failure or cardiac asthma manifested by severe dyspnoea, congestion of lungs, swelling over the feet, tachycardia, angina and anaemia. Although, S3 gallop which is the clinical evidence of Severe LV failure disappeared but there was no special relief to the patient.
Laurocerasus Q was administered after Strophanthus did not ameliorate to satisfaction. Digitalis, Adonis-v, Kalmia and Convalraia were thought of, but finally Laurocerasus was given as a pathological prescription to control the LVF on the basis of Breathlessness < exertion < sitting, palpitations, S/of constriction in the precordium > by massage on the chest. Cough with copious jelly- like expectoration < lying down, night. Edema feet. Valvular disease-Mitral and Aortic regurgitation. The patient improved to a great extent and her failure was controlled.
3. Medorrhinum-the multipolycrest missile was the constitutional remedy, the true Similimum in this case. It was decided on the basis of the detailed case history. Mentally patient had lack of interest and concentration in studies while physically she was stunted and short statured. Fidgety feet, Very obstinate, sensitive with weeping tendency. Hopeless of recovery. Menstrual troubles- profuse, clots dark offensive, stains difficult to wash, dysmenorrhoea > lying on the stomach. Leucorrhoea - thin white, with intense vulval itching. Desires salt, icy cold drinks, Thirst - +++. Anal itching with pinworms. Sleep - sound. Sleeps on the stomach. P/H - RHD, F/H of Brother and PA-RHD, Father- Urethral stricture, PGF-renal stones, Rheumatoid Arthritis.
Within a month itself the patient responded positively. She became mentally calm and her menstrual complaints reduced although the elimination continued i.e. leukorrhoea increased initially, but then gradually decreased. The patient is still under regular follow-up and has started her studies again.
4. POP/O2 inhalation were essential tools in managing the acute scenario along with medicines (F.N aph 67, 6th Ed Org). Psychotherapy and Counseling have also played a very important role in the management of the entire case.