History Taking in Rheumatic Heart Disease (RHD) - Complete OPD Guide

1. BIODATA / PATIENT PROFILE

2. CHIEF COMPLAINT

• Breathlessness (most common)
• Palpitations
• Chest pain/discomfort
• Swelling of legs/abdomen
• Coughing up blood (hemoptysis)
• Fainting/presyncope
• Hoarseness of voice
• Fatigue / reduced exercise tolerance

3. HISTORY OF PRESENTING ILLNESS (HoPi)

A. Dyspnea (Breathlessness) - THE cardinal symptom

• Onset: When did breathlessness first begin? Was it sudden or gradual?
• Grade it using NYHA classification:
  • Class I: No limitation on ordinary activity
  • Class II: Slight limitation; comfortable at rest; symptoms with moderate exertion
  • Class III: Marked limitation; comfortable at rest; symptoms with mild exertion
  • Class IV: Unable to perform any activity; symptoms at rest
• Precipitating factors: Exertion, lying flat (orthopnea), sleep (paroxysmal nocturnal dyspnea), pregnancy, fever, excitement, sexual intercourse
• Orthopnea: How many pillows does the patient need to sleep? When did this begin?
• PND: Does the patient wake up breathless at night? How often?
• Progression: Is it getting worse over time?

Harrison's (2025) notes: "The first bouts of dyspnea are usually precipitated by clinical events that increase the rate of blood flow across the mitral orifice... severe exertion, excitement, fever, severe anemia, paroxysmal AF and other tachycardias, sexual intercourse, pregnancy, and thyrotoxicosis." - Harrison's Principles of Internal Medicine 22E

B. Palpitations

• Character: Regular or irregular? Fast or slow?
• Duration and frequency of episodes
• Ask specifically about atrial fibrillation symptoms - irregular rapid heart beating (AF is a major turning point in MS - accelerates symptom progression)
• Associated dizziness, presyncope, syncope

C. Hemoptysis

• Nature: Blood-streaked sputum, frank blood, or pink frothy sputum (pulmonary edema)?
• Amount and frequency
• Associated triggers
• This is common in mitral stenosis from rupture of pulmonary-bronchial venous connections due to pulmonary venous hypertension

D. Chest Pain

• Character, radiation, precipitating and relieving factors
• Exertional vs. pleuritic vs. constant
• Associated pericarditis (sharp, positional, worse lying flat) vs. angina-like pain from pulmonary hypertension or associated aortic valve disease

E. Edema / Swelling

• Ankle/leg swelling - onset, unilateral vs. bilateral, pitting?
• Abdominal distension (ascites) - develops with right-sided heart failure
• Facial puffiness in the morning?

F. Syncope / Presyncope

• Precipitated by exertion? (suggests critical aortic stenosis or severe pulmonary hypertension)
• Postural? During palpitations?

G. Hoarseness of Voice

• Ortner's (cardiovocal) syndrome - large left atrium compressing the left recurrent laryngeal nerve, seen in severe mitral stenosis
• Duration, progressive or static?

H. Fatigue / Exercise Intolerance

• Reduced exercise capacity, easy fatiguability - reflects reduced cardiac output

4. PAST HISTORY OF RHEUMATIC FEVER (CRITICAL SECTION)

i. Sore Throat / Throat Infection

• History of recurrent sore throats in childhood/adolescence
• Was it diagnosed as streptococcal pharyngitis? Was it treated with antibiotics?
• History of scarlet fever

ii. Joints

• History of migratory polyarthritis affecting large joints (knees, ankles, wrists, elbows)
• "Did the joint pain jump from one joint to another?" - characteristic fleeting, migratory pattern
• Was there swelling, redness, warmth, tenderness?
• Did it resolve completely without joint deformity?
• Arthritis occurs in 60-75% of initial attacks - Tintinalli's Emergency Medicine

iii. Carditis (at the time of ARF)

• Was there any heart murmur detected during childhood?
• Was the child admitted to hospital for heart disease?
• Any history of chest pain, breathlessness, or palpitations during childhood that was attributed to heart disease?

iv. Chorea (Sydenham's Chorea)

• History of involuntary jerky movements of limbs or face in childhood
• Emotional lability, deterioration in school performance, clumsy handwriting
• Duration, treatment received

v. Skin Manifestations

• Erythema marginatum: Pink/red ring-shaped rash on trunk or limbs (non-itchy)
• Subcutaneous nodules: Small, painless lumps over bony prominences (elbows, knees, scalp)

vi. Fever

• Episodes of fever coinciding with joint or heart symptoms in childhood

vii. Number of ARF Attacks

• How many episodes? (Multiple attacks worsen valve disease)
• Age at each attack
• Was there carditis during each attack?

Park's Preventive and Social Medicine notes: "Variables that correlate with the severity of valve disease include the number of previous attacks of RF, the length of time between the onset of disease and start of therapy, and sex."

5. PROPHYLAXIS HISTORY

• Was the patient ever put on secondary prophylaxis (benzathine penicillin injections monthly)?
• Compliance: Were injections taken regularly? For how long?
• Last dose of prophylaxis?
• Penicillin allergy (if so, was alternative given)?
• Prophylaxis duration is especially important - poor compliance leads to recurrent ARF and worsening valve disease

6. COMPLICATIONS - DIRECT QUESTIONING

7. TREATMENT HISTORY

• Current medications: Diuretics, digoxin, beta-blockers, anticoagulants (warfarin/NOACs)
• If on warfarin: Regular INR monitoring? Target range? Any bleeding episodes?
• Any cardiac intervention:
  • Balloon mitral valvotomy (BMV) - when, outcome, any restenosis?
  • Mitral valve repair or replacement - type of prosthesis (mechanical vs. bioprosthetic)?
  • Any other cardiac surgery - aortic valve replacement, tricuspid repair?
• Hospital admissions for heart failure - how many, when, treatment given?

8. OBSTETRIC HISTORY (in Women of Childbearing Age)

• Parity and obstetric outcomes
• Did symptoms worsen during pregnancy?
• Any pregnancy-related cardiac events (pulmonary edema, AF)?
• RHD in pregnancy carries significant maternal risk, especially with MS (increased cardiac output in pregnancy precipitates decompensation)

9. FAMILY HISTORY

• Any family members with rheumatic fever or rheumatic heart disease?
• Congenital heart disease in family?
• Sudden cardiac death in family members?
• (RHD is not directly inherited, but streptococcal infections cluster in families due to shared living conditions)

10. PERSONAL AND SOCIAL HISTORY

• Smoking: Associated with cardiovascular risk, worsens outcomes
• Alcohol: Can precipitate AF, worsens heart failure
• Diet: Sodium intake (relevant in heart failure management)
• Living conditions: Overcrowding, access to clean water, sanitation (risk factor for recurrent streptococcal infections)
• Occupation: Sedentary vs. physical demand; ability to work?
• Dental hygiene: Poor dentition increases IE risk - ask about dental procedures without antibiotic cover

11. REVIEW OF SYSTEMS (Systemic Enquiry)

• Respiratory: Recurrent chest infections, wheeze, cough
• GI: Nausea, anorexia, abdominal pain, jaundice (hepatic congestion in RHF)
• Neurological: TIA, stroke, seizures (embolic events)
• Renal: Reduced urine output (low cardiac output), oliguria
• Musculoskeletal: Joint symptoms (recurrent arthritis from ARF recurrence)
• Constitutional: Weight loss/gain, fever, night sweats (infective endocarditis)

12. FUNCTIONAL STATUS ASSESSMENT

• NYHA Class (I-IV) for dyspnea
• 6-minute walk test capacity (subjective history)
• Activities of daily living: Climbing stairs, housework, walking on flat ground
• Change from previous assessment?

QUICK SUMMARY CHECKLIST FOR OPD

BIODATA         → Age, sex, residence, SES
COMPLAINTS      → Dyspnea, palpitations, hemoptysis, edema, hoarseness
DYSPNEA         → NYHA class, orthopnea, PND, precipitants
ARF HISTORY     → Sore throat, migratory arthritis, carditis, chorea, skin lesions
PROPHYLAXIS     → Penicillin given? Compliance? Duration?
COMPLICATIONS   → AF, embolism, IE, PH, heart failure
TREATMENTS      → Medications, BMV, valve surgery, anticoagulation
OBSTETRIC Hx    → (Women) Pregnancy and cardiac events
FAMILY Hx       → RHD in family, living conditions
SOCIAL Hx       → Smoking, alcohol, overcrowding, dental care

KEY POINTS FOR DOCUMENTATION

1. Always note the age at first ARF attack and number of recurrences - these determine severity
2. Document prophylaxis compliance clearly - this is both prognostic and medicolegal
3. In the Indian subcontinent, a large proportion of patients cannot recall a clear ARF history - still ask specifically; 60% of mitral stenosis patients present without a clear ARF history (Schwartz's Surgery)
4. Atrial fibrillation onset is a critical landmark - document when it was diagnosed and whether it is paroxysmal, persistent, or permanent
5. In women, obstetric history can reveal unrecognized cardiac decompensation during past pregnancies
6. Systemic embolism risk is 10-20% in mitral stenosis with AF - screen for prior TIA/stroke at every visit