2.  28 y/o, Female  Chief Complaint: Dyspnea

3. 3 days PTA Underwent dental procedures 2 days PTA Productive cough with yellowish sputum accompanied by colds Pricking chest pain radiating to the back lasting for more than 30 mins accuring even at rest Fever T 38 0 C, joint pain and myalgia 1 day PTA Increase severity of symptoms with accompanying dyspnea and easy fatigability

4.  (+) frequent streptococcal throat infection in childhood  At age 6- Valvular heart disease w/ monthly injections of Benzathine Penicillin

5.  (+) HPN- grandfather  (+) Heart disease- father

6.  Drowsy, in respiratory distress, prefers the semi sitting position  BP-130/60 PR-124bpm CR- 135bpm,irregulary irregular  RR- 40cpm T 38.5 0 C  Cold, clammy extremities, no active dermatoses  No nasoaural discharge with alar flaring  Moist buccal mucosa, hyperemic posterior pharyngeal wall, tonsils not enlarged

7.  Supple neck, distended neck veins at 4-5cm at 30 0 angle  Symmetrical chest expansion, (+) supraclavicular retractions, coarse crackles over both lung fields  Dynamic precordium, AB at 6 th LICS AAL, (+) heave at L lower parasternal area, (++) impulse at the 2 nd LICS  Apex: S1 vary in intensity, grade 3/6 holosystolic murmur radiating to the axilla; Normal S2, opening snap and grade 3/6 diastolic rumbling murmur  Base: pulmonic component of S2 is loud grade 3/6 diastolic blowing murmur

8.  Globular abdomen, liver is palpable  Extremity: Grade 2 bipedal edema

9.  Dyspnea  Underwent dental procedure  Productive cough with yellowish sputum accompanied by colds  Pricking chest pain radiating to the back lasting for more than 30 mins accuring even at rest  Fever, joint pain and myalgia  (+) frequent streptococcal throat infection in childhood  At age 6- Valvular heart disease w/ monthly injections of Benzathine Penicillin

10.  FH: (+) HPN- grandfather, (+) Heart disease- father  PE findings: drowsy, in respiratory distress, prefers the semi sitting position  BP-130/60 PR-124bpm CR- 135bpm,irreg  RR- 40cpm T 38.5 0 C  Cold, clammy extremities  hyperemic posterior pharyngeal wall, tonsils not enlarged

11.  distended neck veins at 4-5cm at 30 0 angle  Symmetrical chest expansion, (+) supraclavicular retractions, coarse crackles over both lung fields  Dynamic precordium, AB at 6 th LICS AAL, (+) heave at L lower parasternal area, (++) impulse at the 2 nd LICS  Apex: S1 vary in intensity, grade 3/6 holosystolic murmur radiating to the axilla; Normal S2, opening snap and grade 3/6 diastolic rumbling murmur  Base: pulmonic component of S2 is loud grade 3/6 diastolic blowing murmur

12.  Palpable liver  Grade 2 bipedal edema

13. CBC Hgb- 120 N ESR - >100mm/hr ↑ Hct- 40 NASO- >200IU/L ↑ Plt- 305 N WBC-19.9 x10 9 /L ↑ Seg-0.91 ↑ Lympho-0.08 ↓

14.  Cardiomegaly with features of mitral valve pathology  Pulmonary edema  Haziness at the R paracardiac border

15.  Atrial Fibrillation with rapid ventricular response  Non specific ST-T wave changes

16.  Mitral Stenosis, moderate to severe  Mitral Regurgitation, moderate  Aortic Regurgitation, moderate  LV and RV dilatation  Dilated LA and RA w/ no evidence of thrombus  Dilated main pulmonary artery