Cardiology Series: Case 14


A 48-year old female diagnosed with rheumatic heart disease comes into your clinic complaining of increased shortness of breath upon exertion as well as frequent occurrence of palpitations.

From examination you record the following:

  • Engorged vein in the neck
  • Parasternal heave and diastolic thrill
  • S1 is short, sharp and loud and S2 is audible
  • An opening snap was heard after S2
  • Diastolic rumble was heard.

S1=1st heart sound

S2= 2nd heart sound

Image result for mitral stenosis cheeks

1. Which valvular incompetence are you suspecting ? 

2. What do you observe from the picture above that might also suggest this diagnosis ?

3. Describe the significance of an engorged neck vein.

4. What are the lab findings for diagnosing rheumatic fever ?

5. What are the other causes of this valvular incompetence ?

6. What are the complications if this valvular incompetence is left untreated ?

7. How would you manage this patient ?



1. Mitral stenosis

2. Malar Flush on the cheeks

3. In healthy people, the filling level of the jugular vein should be less than 3 centimetres vertical height above the sternal angle. A pen-light can aid in discerning the jugular filling level by providing tangential light.

In this patient, the engorged neck vein is due to increased Jugular Venous Pressure (JVP), accompanied with large ‘a’ waves suggests right heart failure.

4. Lab Findings in Rheumatic Heart Disease

  • Increased WCC (Leucocytosis)
  • Increased ESR & CRP
  • A Prolonged PR interval from ECG (First Degree Heart Block)

Evidence for recent Streptococcal infection

  • Increased anti-streptococcal antibody titres
  • Positive throat cultures

5. All possible Etiologies

Image result for causes of mitral stenosis


6. Complications


a-atrial fibrillation b-bacterial endocarditis c-congestive cardiac failure d-dysphagia
e-embolism f-flutter h-hemiplegia o-ortners syndrome l-levishis syndrome

7. Management

Treatment is not necessary in asymptomatic patients.

The treatment options for mitral stenosis include medical management, mitral valve replacement by surgery, and percutaneous mitral valvuloplasty by balloon catheter.

The indication for invasive treatment with either a mitral valve replacement or valvuloplasty is NYHA functional class III or IV symptoms.

Another option is balloon dilatation.

Treatment of Complications

Any angina is treated with short-acting nitrovasodilators, beta-blockers and/or calcium blockers
Any hypertension is treated aggressively, but caution must be taken in administering beta-blockers
Any heart failure is treated with digoxin, diuretics, nitrovasodilators and, if not contraindicated, cautious inpatient administration of ACE inhibitors.


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