OS 213: Circulation and Respiration (Cardiovascular

Module)
LEC 08: RHEUMATIC FEVER and Rheumatic Heart
Disease
Quiz 1 | Dr. Sanchez-Acosta | July 25, 2012
OUTLINE
I. Rheumatic Fever and
Rheumatic Heart Disease
A. Rheumatic Fever
B. Rheumatic Heart Disease
C. Epidemiology: RF & RHD
D. Risk Factors
II. Rheumatic Fever
A. Pathogenesis of
Rheumatic Fever
B. Etiology
C. Lab Test for GAS
Tonsillopharyngitis
D. ARF: Age & Sex
Distribution
E. Pathology

F. Diagnosis: Jones Criteria

1992
G. Diagnosis: RF Modified
Jones Criteria 1992
H. RF: Other Laboratory
Exams
I. Management
III.Rheumatic Heart Disease
A. Description
B. Diagnosis
C. Medical Management
D. Disease Progression and
Intervention
E. Differentiating RF and
RHD
F. Management
IV. Questions and Answers

RHEUMATIC FEVER AND RHEUMATIC HEART

DISEASE
Rheumatic Fever
Most common cause of acquired heart disease in
children, adolescents and young adults worldwide
Pathology: diffuse inflammation of connective tissues
of heart, joints, brain, blood vessels & subcutaneous
tissues
Rheumatic process, when it heals, causes fibrosis of
heart valves leading to rheumatic heart disease
(RHD) as a sequelae and onset depends whether it
was detected early or not or treated early or not
Relationship with Group A -hemolytic Streptococcus
established

Rheumatic Heart Disease

Chronic valvular heart disease as a sequelae of
rheumatic fever (RF)
When recurrent RF causes scarring of the heart, it
becomes Rheumatic Heart Disease (RHD)
o Must have both the recurrence and the scarring
to consider RHD as a sequelae of RF
o Exactly when?
It depends on the patient when in the
continuum, did he/she sought intervention? does
he/she take medication regularly, etc.

Epidemiology: RF and RHD

Why? they can afford a check-up because they have

the money

Risk Factors
Risk factors for RF
o Poverty
o Poor housing, overcrowded housing
o Reduced access to health care
Risk factor for RHD
o Recurrent episodes of RF
RHEUMATIC FEVER
Pathogenesis of Rheumatic Fever
Actual mechanism unknown
Postulate:
o Autoimmune or hypersensitivity reaction to
Group A Strep (GAS) produces pathogenic autoantibodies to cardiac tissues
o Anti-streptococcal antibodies made by the infected
host cross-react with host connective tissue (ie.
cardiac, pulmonary, synovial, peritoneal) antigens
and lead to end-organ damage by an immunologic
mechanism.
o It is believed to be caused by antibody crossreactivity. This cross-reactivity is a Type II
hypersensitivity reaction
and
is
termed molecular mimicry. Usually, self-reactive B
cells remain anergic in the periphery without T cell
co-stimulation. During a Streptococcus infection,
mature
antigen
presenting
cells
such
as
macrophages present the bacterial antigen to CD4T cells which differentiate into helper T 2 cells.
Helper T2 cells subsequently activate the B cells to
become plasma cells and induce the production of
antibodies against the cell wall of Streptococcus.
However the antibodies may also react against the
myocardium and joints producing the symptoms of
rheumatic fever.
Myocardial
Aschoffs
Body/Nodule

focal
inflammatory lesions in the heart;
swollen
eosinophilic collagen surrounded by lymphocytes and
Anitshkow; cells are large, elongated, with large
nuclei; some are multinucleate.

Table 1. Prevalence of RF and RHD in School

Children
Country
Rate
Developing countries
18.6 / 1000
Philippines
1971-1980
0.9 / 1000
1981-1990
0.6 / 1000
2010
0.5 / 1000
Developed countries
USA
1971-1980
0.7 / 1000
Australia 1981-1990
12.3 / 1000
(because of
aborigines)

Factors in the Development of Rheumatic Fever

Philippines
o In a study at the PGH (1986-1990), the peak
incidence of RF and RHD is from 5-15 years old
o Deaths from RF and RHD (Achutti & Achutti, 1992)
1% of cardiovascular death
200,000 cases/ year
Worldwide (World Heart Federation)
o 15.6 million people affected worldwide
o Almost 500,000 new cases each year
o Approximately 350,000 deaths each year
o Most occur in developing countries (for developed
countries, this is already part of the grand rounds)

o Skin infection only leads to AGN but never RF

Persistence of virulent strain GAS organism
Antibody response
Age: usually at ages 5-15 because of exposure to
school grounds
Genetic or familial tendency: specific B cell
alloantigen (D817) & HLA identified (not yet proven)
Socio-economic status
o Poverty, overcrowded housing, reduced access to
health care still the most common risk factor

JEREEL, SITTI, DAYAN

Site of GAS infection

o Throat rheumatic fever (RF), sometimes acute
glomerulonephritis (AGN)
o If the patient complains to you of tonsillitis, ask
yourself whether it is a viral infection or not
o Check for presence of exudates

No exudate does not mean no risk for RF

Exudate will usually appear after several days so reexamine the patient
If still no exudate, usually viral infection. If with
exudate, consider risk for RF.
Features suggestive of viral etiology: conjunctivitis,
coryza (inflammation of mucus membranes lining the
nasal cavity), cough, diarrhea

UPCM 2016 B: XVI, Walang

Kapantay!

1 of 6

OS 213: Circulation and Respiration (Cardiovascular

Module)
LEC 08: RHEUMATIC FEVER and Rheumatic Heart
Disease
Quiz 1 | Dr. Sanchez-Acosta | July 25, 2012

o In the Philippines (and probably in other developing

countries as well) we are capable of treating it; it is
just that the patients do not have the money to
seek consult
Rheumatic Fever: Attack Rate
Strep, tonsillitis treated penicillin = 0.3%
Strep, tonsillitis, untreated = 3%
Known rheumatic patients with strep infection = 60%

Etiology
Relationship
with
Group
A
-hemolytic
Streptococcus established
Inflammation of pharynx and tonsils patchy
discrete exudates
Good thing its still sensitive to penicillin
Cell wall (virulence factors)
o M-protein
o Induces antibodies
o Serotypes 5, 6 & 19 cross react with myosin
Enzymes
o Streptolysin
o Deoxyribonuclease
o Fibrinolysin
o Diphosphopyridine nucleotidase
o Hyaluronidase

o Valuable for confirmation of previous streptococcal

infections in patients suspected of having acute RF
(ARF) or post-streptococcal glomerulonephritis
(PSGN)
o Helpful in prospective epidemiological studies for
distinguishing patients with acute infection from
patients who are carriers
o A positive anti-streptococcal antibody titers does
not necessarily mean that RF is present, Jones
criteria must still be followed
o cut-off: > 220 units
In summary, the Diagnosis of GAS Tonsillopharyngitis
o Clinical & Epidemiological Findings
o Laboratory test/s throat culture and/or Rapid
Antigen
ARF: Age and Distribution
Most common in ages 5-15 years old
Rare in children less than 5 years old
In the Philippines, with regard to peak incidence,
there are less than 5 cases who are aged 2-3 years
old
Pathology
Exudative degenerative inflammatory lesions
o Transient manifestations
o Responds to anti-inflammatory agents

Proliferative lesions
o Aschoffs nodules

Areas of inflammation of the connective tissue of

the heart, or focal interstitial inflammation
Fully developed: granulomatous structures consisting of
fibrinoid change, lymphocytic infiltration, occasional
plasma
cells
and
characteristically
abnormal
macrophages (may fuse to form multinucleated giant
cells) surrounding necrotic cells
Diagnostic for RF
Done on biopsy but today in RP, not done anymore.

Figure 1. Streptococcal Tonsillopharyngitis. Note

the presence of patchy discrete exudates
(nana) and the beefy-red color of the pharynx
and tonsils which are characteristic of bacterial
(versus viral) tonsillopharyngitis.
Clinical & Epidemiological Finding & Diagnosis of
GAS Tonsillopharyngitis
1.History of exposure
2.Patient aged 515 years
3.Sudden onset sore throat
4.Fever & Headache
5.Inflammation of pharynx and tonsils patchy discrete
exudates
6.Presentation in winter or early spring
7.Tender, enlarged anterior cervical nodes
8.Nausea, vomiting, and abdominal pain
Laboratory Test for GAS Tonsillopharyngitis
Throat swab and culture (gold standard)
o Standard for documentation of GAS in upper
respiratory tract & for confirmation of clinical
diagnosis of acute strep pharyngitis
o If done correctly sensitivity of 90-95%
o Disadvantage there is delay (after about 48
hours) in obtaining the result
Rapid Antigen Detection Tests (RADT) but this is
very expensive so not done anymore
Anti-streptococcal Antibody Titers (done in PGH)
o Can reflect past but not present immunologic
events
o No value in the diagnosis of acute pharyngitis

JEREEL, SITTI, DAYAN

Persists for many years

Diagnosis: Jones Criteria 1992

Establish initial attack of acute rheumatic fever
Not intended
o To establish diagnosis of inactive or chronic RHD
o To measure rheumatic activity
o To predict course or severity of disease
Previous RF or RHD not included as manifestation
Major Manifestations
o Carditis most common among hospitalized
patients
o Polyarthritis most common manifestation overall
(migratory)
o Chorea
o Erythema marginatum (least common)
o Subcutaneous nodule
Minor Manifestations
o Fever (high-grade, should last for at least 5 days)
o Arthralgia
o Increased acute phase reactants: elevated
erythrocyte sedimentation rate (ESR) and Creactive protein (CRP)
o Prolonged PR interval via ECG test will cause 1 st
degree AV block
How to Use Jones Criteria
There is a high probability of RF when the patient has
o 2 major manifestations, or
o 1 major and 2 minor manifestations plus
supporting evidence of preceding GAS infection
(always!)

UPCM 2016 B: XVI, Walang

Kapantay!

2 of 6

OS 213: Circulation and Respiration (Cardiovascular

Module)
LEC 08: RHEUMATIC FEVER and Rheumatic Heart
Disease
Quiz 1 | Dr. Sanchez-Acosta | July 25, 2012

o GAS infection: through (1) antibody sensing and (2)

streptococcal culture gold standard
o Note: manifestations should be two unrelated
symptoms such as if you use polyarthritis as
major criterion, you cannot combine it with
arthralgia as minor and carditis with prolonged
PR interval
o Exception to the rule: Chorea! WHY? Must have
vasculitis to affect the brain which would take
months to come up. By the natural history of
diseases, everything else might have disappeared
at the time of consultation.
Major Manifestation 1: Rheumatoid Carditis
worst sequela and the only symptom that is not selflimiting
Valvulitis means leaky valves
o Most common manifestation and the most severe
o Almost always present
o Primary valvular involvement
o Pancarditis involves all layers of the heart (like
Kawasaki disease)
o Mnemonic: MATP (Mitral, Aortic, Tricuspid
and Pulmonic) in order of being affected the
most
Cardiomegaly
o not present in mild carditis
Resting tachycardia know if the resting
tachycardia is due to fever or carditis
o Usually associated with fever
o General rule in children: an increase of one degree
Celsius in temperature corresponds to an increase
of heart rate by 10 beats per minute
Pericardial friction rub
o Once pericardial effusion is present, no more sound
o Usually seen in post-op patients or usually very
early in a disease
Congestive heart failure
o gallop rhythm (S3)
o muffled heart sounds
o arrhythmia
o Edema in both L and R
o For R: pulmonary edema

Rapid healing without sequelae

o in contrast with Juvenile Rheumatoid Arthritis
which is prolonged and can cause deformities

Usually resolves in <24 hrs when given aspirin

Major Manifestation 3: Chorea
Sydenhams chorea; St. Vitus dance; chorea minor
Rheumatic involvement of basal ganglia & caudate
nucleus
Purposeless & involuntary movement; muscular
incoordination
&
weakness;
darting
tongue;
emotional lability & slurred speech; sudden flinging
of arms; deterioration of handwriting
milk maids sign
Delayed manifestation or self-limiting
Exception to the Jones criteria: when chorea is
present without any other symptoms, automatically it
is rheumatic in origin unless proven otherwise can
stand alone
also an exception: indolent carditis as RF in origin
automatically
Affects adolescents; disappear in 12 wks, even
without treatment; more common in women
Treat with penicillin
Major Manifestation 4: Erythema Marginatum

Not easy to see, usually occurs with fever

Irregularly-shaped and map-like lesion
Distinctive non-pruritic transient rash
Pale centers with round or serpiginous (slowly
progressing/creeping) margin
Blanches
Trunk & proximal extremities; not the face
Urticaria-like but is induced by heat (disappears
when cold so cover with blanket to elicit)

TYPES OF CARDITIS

Mild carditis
o no cardiomegaly and no CHF
o can be cured and the heart can revert back to its normal
state
Moderate carditis
o mild cardiomegaly & CHF
o commonly proceeds to severe carditis
Severe carditis
o cardiomegaly with severe pulmonary congestion or edema
o may die on admission
Echocarditis - Echocardiographic abnormalities
like MVP, MR, or AR in acute rheumatic fever in the absence of
clinical carditis (valvular regurgitation)
Mitral stenosis in children most probably
congenital because you need at least 5 years of RF in order to
produce mitral stenosis
Subclinical carditis
o
Cardiac involvement in the
absence of valvulitis symptoms; diagnosed with 2D echo.
o
Controversy whether to include
subclinical carditis in the modified Jones Criteria
o
Although echocardiography is
of established value in the evaluation & management of

Figure 2. Pink-to-red non-pruritic macules or

papules located on the trunk and proximal limbs
but never on the face. The lesions spread
outward to form a serpiginous ring with
erythematous raised margins and central
clearing.
Major Manifestation 5: Subcutaneous Nodules
Small, firm, painless, freely movable & transient
Extensor surface of elbows, knees, & wrists; scalp &
spinal areas (always palpate cardiac patient of
rheumatic origin in scalp and spine)
Often seen with carditis

Major Manifestation 2: Migratory Arthritis

Most frequent & benign but least specific

Asymmetric & migratory Inflammation
Larger joints: knees, ankles, elbows, wrists
exquisitely painful

JEREEL, SITTI, DAYAN

UPCM 2016 B: XVI, Walang

Kapantay!

3 of 6

OS 213: Circulation and Respiration (Cardiovascular

Module)
LEC 08: RHEUMATIC FEVER and Rheumatic Heart
Disease
Quiz 1 | Dr. Sanchez-Acosta | July 25, 2012

treatment of streptococcus = 10 days of

penicillin to prevent initial attack
o
if patient already has RF upon consultation, still
treat him/her with penicillin for 10 days because
you do not know if strep is still active (treatment is
always 10 days upon initial consult)
o

Table 3. Primary Prophylaxis or Prevention of

Rheumatic Fever
Agent
Benzathine

Figure 3. Nodules are firm, non-tender, free

from attachments to the overlying skin, and they
range from a few millimeters to 1-2cm

Penicillin G
Penicillin V

RF Modified Jones Criteria 1992

Table 2. Major and Minor Manifestations of RF
According to the Jones Criteria
Major Manifestations
Minor Manifestations
Carditis
Fever
Polyarthritis
Arthralgia
Sydenhams Chorea
Elevated acute phase
reactants
Erythema marginatum
Prolonged PR Interval
Subcutaneous nodules
*PLUS supporting evidence of preceding GAS infection

Estolate
Ethylsuccinate

Clinical: Fever must last more than 5 days. Fever must

be at least > 38oC
Arthralgia

o Diagnostic:

ECG PR interval is prolonged suggesting 1o AV block

Increased acute phase reactants: ESR & CRP are
increased
Complete Blood Count (CBC) and Chest X-Ray (CXR) not
specific to RF

of

RF: Other Laboratory Exams

CBC
o Anemia (hemolysis and dilutional anemia due to
heart failure)
o Leukocytosis (inflammation, infection)
ECG
o Sinus tachycardia
o 1o AV blockprolonged PR interval
o No chamber enlargement (as opposed to RHD)
o Rarely 2o AV block, low voltages, ST-T wave
changes
CXR
o Normal (but may depend on severity of valvular
lesion)
o Cardiomegaly
o Pulmonary congestion and edema
Management
Prophylaxis
Anti-inflammatory agents

Durati
on
Once

Oral

10 d

Oral

10 d

20-40 mg/kg/d

Oral

10 d

2-4 x /day
(max: 1g/d)

Oral

10 d

40 mg/kg/d
2-4 x daily
(max: 1g/d)

Oral

10 d

600,000 U for patients

27 kg
1,200,000 U for
patients
27 kg
Children:
250 mg 2-3x/day
Adolescents/adults:
500 mg 2-3x/day

500 mg on first day

Oral
5d
250 mg/d for the next 4
d
Bonow et al., ACC/AHA TASK FORCE REPORT JACC Vol. 32, No.
5, Nov 1998: 1486-1588ACC/AHA Guidelines for the
Management of Patients WithValvular Heart Disease

Secondary Prophylaxis : prevents recurrences

of RF
o Penicillin (PCN) VK 250 mg twice daily
o Benzathine PCN 1.2 M units every 21 days best choice because long acting, cost effective and
due to good compliance; administered via the
intramuscular route or depot because this
makes the levels in the blood constant
for Filipinos: every 21 days because penicillin levels go
down after 21 days
Short acting benzyl penicillin
Oral penicillin - 2x a day for 10 days (important to
stress compliance with the number of days the
antibiotic is administered to ensure that the
microorganism will be completely eradicated)
Azithromycin - given only for 5 days

o Duration of
recurrence)

Primary prophylaxis : prevents 1st episode of

RF

2o prophylaxis (or prevention of

Arthritis - minimum of 5 years or until age 21

whichever is longer assuming no recurrence of the
disease between 5-21 years. If there is recurrence, add
more 5 years from last onset.
Carditis - at least 10 years assuming recurrence free &
no residual heart disease or 21 whichever is longer
if RHD, long-term prophylaxis because of scarring
if both are present, choose the long-term so treat
carditis!

Table 4. Secondary Prevention of Rheumatic

Fever
Agent
Benzathine
Penicillin G

Prophylaxis

JEREEL, SITTI, DAYAN

Mod
e
IM

Azithromycin

Notes minor manifestations

o Clinical vs Diagnostic

Jones Criteria 1992, Supporting Evidence

Antecedent Group A Streptococcal Infection
o Positive throat culture or rapid antigen test
o Elevated or rising Streptococcal antibody titer

For people
allergic to
Penicillin:
Erythromycin

Dose

Penicillin V

Dose
1,200,000 U every 21
days for Filipinos (very
important!!!!!!)
(every 3 wk for high risk
patients such as those with
residual carditis)
250 mg 2x/day

UPCM 2016 B: XVI, Walang

Kapantay!

Mode
IM

Oral

4 of 6

Sulfadiazine

OS 213: Circulation and Respiration (Cardiovascular

Module)
LEC 08: RHEUMATIC FEVER and Rheumatic Heart
Disease
Quiz 1 | Dr. Sanchez-Acosta | July 25, 2012
0.5 g once daily for patients
27 kg
1.0 g once daily for patients
27 kg

Oral

For people allergic

to penicillin and
sulfadiazine:
Erythromycin
250 mg twice daily
Oral
*High-risk patients include those with residual rheumatic
carditis as well as patients from economically disadvantaged
populations.

Table 5. Duration of Secondary Prophylaxis

Group
ARF
(no carditis)
Mild-moderate
carditis
(or healed carditis)

Duration of Secondary
Prophylaxis
Minimum of 5 years after last ARF,
or
Until age 21 years whichever is
longer
Minimum of 10 years after last ARF,
or
Until age 25 years (whichever is
longer)
Continue for life

Severe RHD; after

surgery
a
2007 World Health Federation
b
We start counting the duration of prophylaxis WHEN
rheumatic fever is cured
c
For carditis, you start counting 10 years from the time the
heart was cleared from carditis
d
In the Philippines, the cut off age is 21 years

Anti-inflammatory Agents
For 6-8 weeks
o prednisone 2 mg/kg/day
o aspirin 100 mg/kg/day

plus complete bed rest for at least 3 months for

severe carditis (may even stop schooling)

RHEUMATIC HEART DISEASE

Description
Heart disease as a sequelae of chronic RF and its
recurrences
Heart valves are scarred due to healing process
following ARF
RHD is more likely to develop following ARF if
o The initial episode of ARF was severe
o The heart was affected with ARF
o ARF occurred at a young age
o There has been recurrent ARF
50% of people with RHD do not remember
having ARF because some symptoms are self-limiting
Valve Regurgitation suggests that heart valves
o Are thickened and stick against the walls of the
heart
o Leakage (the blood flows backwards over the
valve)
Valve Stenosis suggests that heart valves
o Become stiff
o Do not allow blood to flow through easily
(restricted forward flow)

Diagnosis
Clinical history and physical examination
Blood examinations (CBC, ESR, Anti-Strep Antibody
Titers, CRP, blood culture study) & urinalysis

ECG and CXR

Echocardiography:
TTE
(transthoracic),
TEE
(transesophageal)

Mitral Regurgitation

a pansystolic murmur heard loudest at the

apex and radiating laterally to the axilla; soft S1

JEREEL, SITTI, DAYAN

Why does it radiate to the axilla? the left

atrium is the most posterior chamber of the heart

Most common
o ECG - normal; LAE, LVH
o CXR - normal; LAE, LVH; pulmonary congestion
o Echo - thickened valve; dilated MV annulus; ECGNormal; LAE, LVH
Mitral Stenosis
low-pitched, diastolic rumble heard best at the apex
with the bell of the stethoscope and with the person
lying in the left lateral position.
Once the mitral valve is damaged, when the patient
is cured it can return to its normal state
When the aortic valve is damaged, it cannot return to
its original state, its forever damaged
o In 10-30% of cases
o Produces a thrill upon PE; though not all do
ECG - Normal; LAE, RVH
CXR - LAE, RVH; Pulmonary congestion; Dilated MPA
Echo - Thickened fixed leaflets; Small MVA (fishmouth
commisure)
History of CHF, RVF

Aortic Regurgitation
a diastolic blowing decrescendo murmur best heard
at the left sternal border with the person sitting up
and leaning forward in full expiration
ECG - LVH; Strain pattern
CXR - LVH; Dilated aorta
Echocardiogram - thickened leaflets with prolapsed
Heave indicative of volume overload
Fibrosis and contracture of the aortic valve
Regurgitation across incompetent valve, increase in
LV volume, aortic run-off LV dilation decreased
myocardial contractility
Rarely isolated (bicuspid aortic valve if isolated);
usually with MR
Prominent carotid pulse
Corrigans pulse
Natural History: CHF, chest pain (in AR vs MR),
infective endocarditis
o Ischemic AR less coronary perfusion during
diastole
Others

Aortic stenosis: not common; if there is, then its

most probably congenital
Tricuspid regurgitation
Tricuspid stenosis: rare (least common)
Pulmonary regurgitation: related to pulmonary
hypertension
Pulmonary stenosis: very rare

Summary of ECG and CXR

ECG
Normal if lesions are mild
MR: LAE, LVH
MS: LAE, RVH
AR: LVH
TR: RAE, RVH

Chest X-Ray
o Pulmonary venous congestion;
chronic & severe lesions
o
o
o
o
o

dilated

MPA

if

Medical Management
Anti-CHF

UPCM 2016 B: XVI, Walang

Kapantay!

5 of 6

OS 213: Circulation and Respiration (Cardiovascular

Module)
LEC 08: RHEUMATIC FEVER and Rheumatic Heart
Disease
Quiz 1 | Dr. Sanchez-Acosta | July 25, 2012

o ionotropes
(dopamine);
diuretics
and
ACE
inhibitors; -blockers only if with arrythmia
2o prophylaxis Benzathine penicillin- 21 days
Infective Endocarditis prophylaxis
o antibiotics
Anticoagulant (coumadin) so that there will be no
thrombus
Arrhythmia management
Surgical
o
MR - Valvuloplasty, annular placation,
valve replacement
o
MS Commisurotomy
o
AR - Valvuloplasty or valve replacement
Remember:
o If porcine valves used, need to be replaced later in
life due to calcifications
o If pediatrics patient, primary drug to give are
diuretics because it will relieve pulmonary causes
of RHD (remember, children rely more on breathing
for survival)
o MI in children mainly due to pulmonary congestion
Disease Progression and Intervention
Primary Prophylaxis

END OF TRANSCRIPTION

Ate Dayan:
Sitti: Hello everyone. Watch out for RF. Baka nagkaron kayo
ng symptoms nung bata pero di nyo lang matandaan. Hala
Joke lang, dont be paranoid. Guys watch Bourne Legacy, hindi
ko alam kung maganda, promote lang dahil shinoot sa Manila.
RSO and MSSR are selling tickets for the benefit of a very
unfortunate elementary school and Unang Yakap Program
Jereel: Babawi ako sa greeting dahil nakalimutan ko sa first
trans namin. hahaha. Anyway, hi 2016! helLU4 na! Sana okay
pa tayong lahat. Hi Block A friends kung mababasa ninyo to.
And syempre, hello Block B! Ang toxic ng cardio pero sana
kayanin natin! MSSR-IPPNW go! Kung interested kayo,
pwede pa mag-apply. Wag kayong matakot, sobrang mababait
kami. heehee. Nood nga pala kayo ng block screening ng
Bourne Legacy by MSSR and RSO! woohoo! Hello sa
Mangotukola! I miss yall and our toxic days NOT. haha. Hello
to my new seatmate Tato. Hello bestie Allie! Hello nga pala
kay Niko! Nami-miss na kita. Wala na kong kinikiliti. Wag
masyadong malandi ah. Ikaw na bahalang maghanap ng MTTh
sched niya. hahaha. Hoy Clintaba! Wag kang mag-IPad
forever. Umayos ka! hihi. Hoy Jim! Naiintindihan ko na hindi
tayo mag-seatmate dahil busy ka. Sinusuportahan kita dyan
pero hinay-hinay lang ha! ;) Heya virGinnie! AlexeisCelina(block A ), coffee shop review na! Oi Jer, kumusta ang
mebendazole mo? haha. Good luck sa atin sa cardio. Kayanin
natin ang lahat ng transes!

Jones Criteria, 20
Prophylaxis
Tertiary Prophylaxis

Medication of Penicillin only

Figure 4. Summary of the Lecture (Important!)

Differentiating RF and RHD

Table 5. Differences Between RF and RHD

Management
Education (most important)
o you really have to make them understand their
situations especially the parents and unruly
adolescents
Adherence to secondary prophylaxis
Regular
clinical
assessment
and
follow-up
echocardiography
Management of cardiac failure
Management of atrial fibrillation
Dental care and Infective endocarditis prophylaxis
Family planning referral (for women)
Vaccination
Appropriate surgical intervention

QUESTIONS AND ANSWERS

Indications for tonsillectomy
o repeated acute tonsillitis with treatment for a year
o obstructive apnea
We still dont know yet if there is a genetic factor but
there is a familial predisposition

JEREEL, SITTI, DAYAN

RF

RHD

History (not
always useful)

symptoms occur
early, usually in
younger
population

can be initially
asymptomatic
but is actually
chronic: usual in
adults but not
always

CXR

Valvular lesions

Valvular lesions;
with pulmonary
artery
hypertention
(dilated vessels)

PE

No chronic heart
disease

Precordial bulge

ECG

No tachycardia,
chamber
enlargement

Prognosis

Px, heart
structures return
to normal

Valvular disease
which is lifetime

UPCM 2016 B: XVI, Walang

Kapantay!

6 of 6