1. GARCIA MJ, GARZON MMP, GASPAR IV, GATCHALIAN C, GAW MG, GERALDOY YR Pediatrics Cardiology Conference

2. Patient JMS 8 years old/F June 19, 2002 456 Lambakin, Marilao, Bulacan Roman Catholic Filipino Informant : Mother Reliability: Good

3. Chief Complaint unsteady gait

4. History of Present Illness 4 wks PTA  (+)decreased appetite  (+) decreased activity level  (+)episodes of joint mild pains  relieved by rest 3 wks PTA  (+) undocumented fever with cough, colds and difficulty of breathing  paracetamol 250 mg tab ½ tab every 4 hours,  salbutamol + carbocisteine (Solmux) 2mg/500mg/5ml 5mL twice a day,  Vitamin C 5 mL once daily  nebulized with 1 salbutamol nebule  symptoms have resolved

5. History of Present Illness 2 wks PTA  (+)decreased appetite, decreased activity  (+)decreased interaction with family relatives  At school:  patient does not maintain good eye contact  kept on moving a lot and cannot stay still during recitation 1 wk PTA  (+)frequently drops and loses her pen in class  (+)hard time gripping her utensils while eating 3 days PTA  wobbly gait, with weak voice and slurred speech

6. History of Present Illness 1 day PTA  increased movement while sleeping  persistence of symptoms  St. Michael Hospital  Referred to a private neurology physician, they were referred to Neurology Pediatrics  patient was brought to Jose Reyes Hospital A>>Rheumatic Heart Disease  Lack of bed, hence patient was brought to our institution.

7. Review of Systems General: (+) weight loss (-) delay in growth Cutaneous: (-) rashes, (-) active dermatoses, (-) hair loss Respiratory: (-) chest pain, (-) cough, (-) difficulty of breathing Cardiovascular: (-) orthopnea, (-) cyanosis, (-) easy fatigability Gastrointestinal: (-)vomiting, (-) jaundice, (-) diarrea (-) constipation

8. Review of Systems Genito-urinary: (-) hematuria, (-) change in urine frequency (-) dysuria Endocrine: (-) heat/cold intolerance Musculoskeletal: (-) gross deformities, (-) edema Hematopoietic: (+) pallor, (+) easy bruisability, (-) epistaxis Nervous/Behaviour: (-) seizures (-) sleep problems, (-) convulsions (-) paralysis

9. 24 hour food recall MealFoodCHOCHONFATSKCAL Breakfast 1 pcHotdog-810122 1 cupRice464-200 Lunch ½ cupRice232-100 ½ pcHotdog-4561 1 packPancit canton232-100 Dinner 1 cupRice464-200 1 pcChicken fillet-164100 ACI883 RENI1600 % 55.19% Ideal Body Weight: Age in year x 2 + 8 = 24 kg

10. Past Medical History Asthma – 7 years old – given salbutamol nebulization when needed UTI – 4 years old – was given unrecalled antibiotics for 1 week- consult done at OPD Immunization History Mother claims that patient has completed immunizations until 9 months in a local health center. Developmental History *at par with age Can do complex pattern movements Can tell time Reads for pleasure Can do concrete operations Accepts rules

11. Family History MemberAgeRelationEducational Attainment OccupationHealth Jose39FatherEngineering Cell site caretaker Healthy Rosalinda38Mother High school graduate Textile factory worker Healthy Jasmine1Sister--healthy (+) goiter – grandmother, 1 uncle, 2 aunts (+) cancer – grandmother: brain cancer “lymphoma” (-) HPN, stroke, DM, asthma, allergy, kidney disease, blood dyscrasia, TB, Seizures Family Profile

12. Personal, Socioeconomic and Environmental History The patient lives with her parents in a well lit well ventilated house made of concrete. Purified water is used for drinking and is not boiled. Garbage is segregated and collected everyday by municipal trucks. There are no pets, no factories nearby. Average monthly income of P15,000.

13. Physical Examination on Admission Alert, awake, not in cardiorespiratory distress, well hydrated, well nourished VS: BP: 110/70 HR 99 bpm RR 16/min T 36.5C Wt : 31.5 kg (z = above 1) Ht : 137 cm (z = above 1) BMI : 16.78 (z = above 0) Warm, moist skin, no active dermatoses EENT: Pink palpebral conjunctivae and anicteric sclera, no tragal tenderness, no aural discharge, non-hyperemic external auditory canal, midline nasal septum, turbinates not congested, no nasal discharge, moist buccal mucosa, (+) hyperemic posterior pharyngeal wall, tonsils not enlarged

14. Physical Examination on Admission Supple neck, (+) palpable cervical lymph nodes Symmetrical chest expansion, no retractions, clear breath sounds Adynamic precordium, apex beat at 5 th LICS MCL, no murmurs Flat abdomen, soft, non-tender, normoactive bowel sounds, no masses palpated No cyanosis, no edema, pulses full and equal on all extremities

15. Neurological Examination Conscious, coherent, oriented to time, place and person can smell, pupils 2-3 mm isocoric ERTL, (+) direct and consensual light reflex, no visual field cuts, (+) ROR, EOMs full and equal, sensory deficit on R side of face, can clench teeth, can raise eyebrows, can close eyes tightly, can smile, no hearing deficit, no lateralization on Weber’s, AC > BC, uvula midline, can shrug shoulders equally, can turn head from side to side against resistance, tongue midline on protrusion,

16. Neurologic Examination Good muscle bulk, no fasciculation, no atrophy No spasticity, no rigidity MMT 5/5 on all extremities Sensory deficit on L upper & lower extremities Can do FTNT, APST, with involuntary movements of extremities DTRs ++ on all extremities (+) Babinski, (-) nuchal rigidity, (-) ankle clonus

17. Subjective Objective 9yr old/female Unsteady gait (+)decreased appetite, (+) decreased activity level (+)episodes of joint mild pains (+) undocumented fever with cough, colds and difficulty of breathing (+) poor eye contact, interaction Frequently drops her pen and hard time gripping her utensils wobbly gait, with weak voice and slurred speech increased movement while sleeping (+) hyperemic posterior pharyngeal wall (+) palpable cervical lymph nodes sensory deficit on R side of face Sensory deficit on L upper & lower extremities Can do FTNT, APST, with involuntary movements of extremities (+) Babinski Salient Features

18. Course in the Wards

19. 1 st Hospital Day Patient was hydrated with Plain NSS 1L at 18-19 drops/min

20. Normal RangeResult Hgb115-155113 RBC4.33 Hct0.35-0.450.35 Platelet150-450346 WBC4.5-13.58.30 Neutrophils0.54-0.620.47 Segmenters0.54-0.620.47 Lymphocytes0.25-0.330.42 Eosinophils0.01-0.030.11

21. Blood chemistry: Cranial MRI with contrast :  normal contrast-enhanced cranial MRI Normal RangeResult Creatinine0.470.4-0.6 Sodium138138-146 Potassium3.903.5-5 Total Calcium9.328.8-10.8

22. Salbutamol nebulization given 15 minutes prior to scheduled MRI. Patient was also referred to the service of Pediatric Cardiology and Pediatric Neurology. (video)

23. 2 nd Hospital Day On repeat physical exam, grade 2-3/6 holosystolic murmur at the left parasternal area was appreciated by Pediatric Cardiology Chest x-ray was done

24. cardiomegaly, pulmonary congestion

25. 2nd Hospital Day ASO titer high at 598.01 (N.V. 0-240 IU/mL). 12-lead ECG  sinus tachycardia, normal axis within normal limits

26. 3 rd Hospital Day Patient complained of oral sores in the inner lower lip  Solcoseryl paste was given Pedia Neuro started Valproic acid 250mg/5ml 5mL q12h

27. 4 th Hospital Day Patient was re-examined by Pediatric Cardiology 2D-Echocardiography:  Minimal posterior pericardial effusion  1-2 aortic regurgitation  2-3 mitral regurgitation  Normal coronary arteries  Dilated Left ventricle  Good contractility indices  No structural defects  Apparent prolapse of the anterior leaflet which appear to be slightly thickened and deformed

28. Benzathine Penicillin G 1,200,000 IU/IM injection every 4 weeks Digoxin 0.25 mg/tab ½ tab BID

29. 8 th Hospital Day Valproic Acid was discontinued Prednisone 20mg/tab was started at 1 tablet by mouth TID after meals

30. Last Hospital Day Final diagnosis: Rheumatic Heart Disease Take home medications:  Prednisone 20mg/tab at 1 tab three times a day after meals  Ranitidine 150mg/tab 1 tab twice a day  Digoxin 0.25mg/tab at ½ tab twice a day  Benzathine penicillin G 1.2 M IU/IM every 4 weeks