What is the appropriate approach to taking a history and conducting a physical examination in a patient with rheumatic heart disease?

History and Physical Examination of Rheumatic Heart Disease Patients

When evaluating a patient with rheumatic heart disease, obtain a detailed history of acute rheumatic fever episodes, document current cardiac symptoms with specific attention to dyspnea patterns and volume status, and perform a focused cardiovascular examination targeting valvular abnormalities and heart failure signs.

Essential Historical Elements

History of Acute Rheumatic Fever

• Document any history of acute rheumatic fever/carditis, typically determined through correspondence with major and minor Jones Criteria 1
• Record the year of the first episode of acute rheumatic fever, as this establishes disease chronicity 1
• Inquire about childhood pharyngitis episodes, particularly those occurring during childhood and adolescence when abnormal immune responses to group A streptococcal infections typically occur 2, 3
• Ask about recurrent episodes of acute rheumatic fever, as multiple episodes lead to cumulative valvular damage 3

Valvular Disease History

• Obtain history of valve disease with echocardiographic findings suggestive of or diagnostic of rheumatic valvular disease 1
• Note the preferential involvement of the mitral valve, as this is characteristic of rheumatic heart disease despite unclear pathological mechanisms 4
• Document any previous valve surgeries or interventions 1

Current Cardiac Symptoms

Dyspnea Assessment:

• Dyspnea at rest: Ask if the patient experiences frequent uncomfortable awareness of breathing while resting in a sitting position, documenting date of onset and duration 1
• Dyspnea on exertion: Quantify the degree of activity required to elicit symptoms—running, walking up an incline (specify distance), walking on flat surface (specify distance), stopping to rest while dressing, or standing (specify time) 1
• Orthopnea: Determine if the patient experiences uncomfortable breathing while supine, requires 3 or more pillows to sleep, or has recurrent supine cough without other known cause 1
• Paroxysmal nocturnal dyspnea: Ask about awakening suddenly from sleep with breathing difficulty or distress relieved by upright position, considering any episode lasting greater than 5 minutes as positive 1

Volume Status Indicators:

• Weight changes: Document amount of weight gain or loss in pounds or kilograms and the timeframe over which it occurred 1
• Swelling: Ask about puffiness in extremities, abdomen, or other areas, with date of onset and duration 1
• Fatigue: Inquire about unusual tiredness and inability to perform usual activities 1

Associated Cardiovascular History

• History of cerebrovascular disease: Document any stroke, transient ischemic attack, or carotid disease, as RHD patients may have embolic complications 1
• History of arrhythmias: Ask about atrial fibrillation or other arrhythmias common in chronic valvular disease 1
• History of heart failure: Document any previous episodes of decompensated heart failure 1

Family History

• Three-generation family history should be obtained to identify relatives with cardiomyopathy, sudden unexplained death, conduction system disease, and skeletal myopathies 5
• Family history of rheumatic fever or early cardiovascular death 1

Social and Environmental History

• Living conditions and socioeconomic status, as RHD is fundamentally a disease of poverty 2, 6
• Access to healthcare and previous antibiotic prophylaxis compliance 2
• Geographic origin, particularly from low- and middle-income countries where RHD burden remains high 2, 6

Medication History

• Current medications, particularly anticoagulation status if atrial fibrillation is present 1
• Penicillin prophylaxis history, as this remains the mainstay of secondary prevention 3, 6
• Medications that alter heart rate and blood pressure 1

Physical Examination Components

Vital Signs

• Heart rate: Note if <40 or >100/min, which indicates hemodynamic instability 7
• Blood pressure: Document if systolic BP <100 or >200 mmHg 7
• Assess for cold extremities as a sign of poor perfusion 7

Cardiovascular Examination

Inspection:

• Assess level of consciousness and overall appearance 7
• Look for signs of volume overload: peripheral edema, jugular venous distension 1

Auscultation:

• Listen for abnormal heart sounds or murmurs characteristic of valvular disease 1
• Identify a third heart sound (S3), which has prognostic significance in heart failure 1
• Document any new aortic regurgitation murmur or changes in existing murmurs 7

Palpation and Percussion:

• Assess jugular venous pressure, as elevated JVP has prognostic significance 1
• Palpate for hepatomegaly and ascites as signs of right heart failure 1
• Check for peripheral edema in extremities 1

Pulmonary Examination

• Auscultate for wheezes or other adventitious sounds to assess for pulmonary congestion 1
• Listen for rales indicating pulmonary edema 1

General Physical Findings

• Assess for signs of chronic illness related to long-term valvular disease 1
• Document any musculoskeletal abnormalities, as collagen vascular disease can coexist 1

Critical Pitfalls to Avoid

• Do not rely solely on clinical examination to exclude significant valvular disease, as echocardiography is essential for accurate diagnosis and severity assessment 1, 3
• Do not assume absence of symptoms means absence of disease, as subclinical rheumatic valve lesions can be identified through ultrasound screening 2
• Do not overlook the importance of documenting compliance with penicillin prophylaxis, as this is the only proven intervention to prevent recurrent episodes and progressive valvular damage 3, 6
• Remember that RHD shows different natural history compared to degenerative valve diseases, requiring specific attention to its unique clinical presentations 4

Documentation Requirements

• Record all findings systematically, including external appearance, cardiac auscultation findings, signs of heart failure, and any evidence of complications 1
• Document functional status using structured assessment of dyspnea patterns and activity limitations 1
• Note any changes since last visit (better, worse, unchanged) for all symptoms 1