RHEUMATIC HEART DISEASE
Intake Form
TODAY'S DATE _______________
DATE OF LAST VISIT TO BAYALPATA OR
___________________________________
[ ] NEW PATIENT
Followed previously at: _______________________
[ ] NO PREVIOUS R.H.D. DIAGNOSIS / OR
[ ] CONFIRMED DIAGNOSIS ELSEWHERE? DATE/ LOCATION OF DIAGNOSIS
_____________________________________________
HAS THE PATIENT EVER HAD A CONGESTIVE HEART FAILURE EXACERBATION
[ ] no [ ] yes (date)?__________________ Where treated [ ] home [ ] inpatient ?__________________
NUMBER OF EXACERBATIONS WITHIN 12 MONTHS
DIAGNOSTIC CLUES Symptoms of Heart
[ ] 1 [ ] 2 [ ] >/3
PAST DIAGNOSTICS (date/result)
[ ] Chest xray
___________________________________
[ ] EKG
___________________________________
[ ] Echocardiog
___________________________________
EXPOSURES
Smoking history No [ ] Yes [ ]
Pack years
[ ] Acute illness in school age children 5-15
[ ] Objective evidence of a preceding group A streptococcal infection
(including elevated or rising ASO titers, or positive microbiologic tests)
PLUS 2 major or 1 major+2 minor
Major
Minor
Clinical
1. Fever ≥ 38˚C
2. Arthralgia
Laboratory
3. Elevated acute phase
reactants (erythrocyte
sedimentation rate ≥ 30
mm/h)
4. PR-interval
prolongation
NOT STRICTLY MEETING CRITERIA, STILL +RF
[ ] 1/Chorea as the only manifestation (abrupt, nonrhythmic
involuntary movements, muscular weakness, and emotional
disturbance) OR
[ ] 2/ Indolent carditis as the only manifestation in patients
who come to medical attention months after acute GAS infection.
[ ] +On exertion [ ]
[ ] Paroxysmal nocturnal
[ ] Cough
Alcohol No [ ] Yes [ ] Details:
HISTORY OF RHEUMATIC FEVER ?
1. Carditis or subclinical
(echocardiographic) carditis
2. Polyarthritis or
monoarthritis
3. Chorea
4. Erythema marginatum
5. Subcutaneous nodules
Failure :
[ ] Dyspnea
Orthopnea
dyspnea
[ ] Edema
HOME MEDICATIONS
CARDIAC
_______________________
_____________
____________________
________________
_________________
___________________
______________
OTHER (list
indication/dose/duration)
______________
___________________
_________________
________________
____________________
_____________
RHEUMATIC HEART DISEASE Examination / Follow Up
TODAY'S DATE _______________
FIRST ONSET AT RHEUM FEVER (/SUSPECTED)
LIST CURRENT MEDS:
[ ] penicillin for secondary prophylaxis SEE #
[ ] heart failure medications – (circle ) ACEi, Bblocker,
furosemide
AGE/SEX
_________________________________
_________________________________
_________________________________
NON COMPLIANCE + REASON [ ] No
[ ] Yes______________________
CHIEF COMPLAINT
SYMPTOMS OF HEART FAILURE TODAY?
[ ] NO [ ] YES- pick one below
IF YES, ASSESS SEVERITY ( NYHA CLASSIFCATION)
[ ] Class I — symptoms of HEART FAILURE only at activity levels that
would limit normal individuals
[ ] Class II — symptoms of HEART FAILURE with ordinary exertion
[ ] Class III — symptoms of HEART FAILURE with less than ordinary
exertion
[ ] Class IV — symptoms of HEART FAILURE at rest
CHIEF COMPLAINT
_________________________________
NEW SYMPTOMS/HISTORY PRESENT ILLNESS
TYPE OF MURMUR DOCUMENTED PRIOR
VISIT
[ ] Mitral Regurg
[ ] Mild
[ ] Mitral Stenosis
[ ] Moderate
[ ] Aortic Regurg
[ ] Severe
[ ] Aortic Stenosis
[ ] Other
ANY SUSPICION TODAY OF RECURRENT RHEUMATIC FEVER
[ ] NO [ ] YES ____________________
(SEE CRITERIA ON INTAKE FORM)
PHYSICAL EXAM
VITALS BP
HR
RR
GENERAL ?visibly dyspneaic
NEURO
NECK ?jugular venous distension
CARDIO ?murmur ?irregular
LUNGS ?crackles
ABDOMEN ?palpable liver
EXTREMITIES ?edema
SKIN
MEDICATIONS/TREATMENT
No drugs affect clinical course BUT chronic antibiotic
therapy can prevent RF recurrence
[ ] Patients with mild carditis (eg, mild mitral
regurgitation or healed carditis) should receive secondary
prophylaxis for 10 years after the last attack or at least
until 25 years of age (whichever is longer)
[ ] Patients with more severe valvular damage (eg,
causing heart failure), or after valve surgery, should
receive lifelong secondary prophylaxis.
PROPHYLAXIS #
Benzathine penicillin G
Adults >27kg =
1.2 million units IM once / 4 weeks
Children <27kg =
600 000 units IM once/ 4 weeks
SAT
T
MURMUR TYPE NOW
copy from left*
NEW DIAGNOSTICS 1/ CXR if unclear diagnosis / clinically worse
ASSESSMENT AND FOLLOW UP
[ ] Clinically stable, age<25 or <10 years after last attack cont q1month
penicillin secondary prevention
[ ] Clinically stable off antibiotic prophylaxis q6 month visit
[ ] Severe symptomatic valvular disease → advise/counsel patient about
need for valvuloplasty/surgery (dyspnea, reduced exercise tolerance,
exertional chest pain, lightheadedness, and syncope)
[ ] Acute CHF decompensation-> see CHF algorithm
[ ] Recurrent Rheum Fever-> send to ER for treatment