Clinical Scenario:
A 12-year-old boy presents with palpitations and shortness of breath on exertion. Six months ago, he had an episode of fever associated with joint pains. On examination, his pulse rate is 120/min, respiratory rate is 28/min, and temperature is 98.8°F. Precordial bulging is noted. Both S1 and S2 are audible, and a pansystolic murmur is heard best at the apex.
What is the most likely diagnosis?
A. Ventricular septal defect (VSD)
B. Mitral valve prolapse
C. Rheumatic heart disease
D. Infective endocarditis
E. Innocent murmur
Correct answer & Explanation:
Answer: C. Rheumatic heart disease
Explanation: Rheumatic heart disease
The history of fever and joint pains suggests a previous episode of rheumatic fever. A pansystolic murmur best heard at the apex is characteristic of mitral regurgitation, the most common valvular lesion seen in rheumatic heart disease. Patients may present months or years after the acute episode with symptoms related to valvular dysfunction, such as palpitations and exertional dyspnea.
Why not the other options?
- A. Ventricular septal defect (VSD): Typically presents in infancy with tachypnea, poor feeding, recurrent respiratory infections, and a pansystolic murmur best heard at the lower left sternal border.
- B. Mitral valve prolapse: Usually presents with a mid-systolic click and late systolic murmur. The history of rheumatic fever strongly favors rheumatic heart disease.
- D. Infective endocarditis: Commonly presents with persistent fever and systemic signs of infection, which are absent in this case.
- E. Innocent murmur: Innocent murmurs are soft, non-pathological murmurs and are not associated with symptoms such as palpitations, dyspnea, or precordial bulging.
