RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE

Regente Imperial Lapak, MD, FPPS, DPCC

October 9, 2014, 8:00 – 10:00 (A/B)
Pediatrics
“God is the great physician. We are simply his instruments for healing. Always keep that in mind.” –Dr. Lapak

OUTLINE PATHOPHYSIOLOGY
 Definition
 Epidemiology GROUP A STREPTOCOCCUS
 Pathogenesis (Rheumatogenic Strains Serotype M1, 3, 5, 6, 18)
(Mucoid)
 Clinical Diagnosis: Jones Criteria
 Primary and Secondary Prevention
 Duration of Secondary Prevention SUSCEPTIBLE HOST
(Positive for HLA DR,4, 2, 1, 3, 7, Dw10, DRw53 and/or Allotype
 Antiiflammatory Treatment D8/17)
 Complications

RHEUMATIC FEVER
 It is an abnormal, delayed, often recurrent, IMMUNE REACTION
(Cross-Reactivity and/or Cell-Mediated Immunity)
probably auto-immune reaction to group
A-beta hemolytic streptococcal
pharyngitis involving the joints, skin,
brain, serous surface and heart TISSUE ORGAN
 The subsequent chronic valvular (Inflammation of Heart, Joints, Brains, Vascular, Connective
Tissue)
involvement secondary to bouts of
rheumatic fever attacks and recurrence is
rheumatic heart disease
 Most common cause of acquired
RHEUMATIC FEVER
disease in children more than five
years of age in the Philippines
In America, the most common is Kawasaki Disease. Not all Group-A Strep organisms can cause rheumatic
fever; only the strains that are mentioned above.
 It is generally classified as a post-
infectious, connective tissue disease CLINICAL MANIFESTATIONS
 Streptococcal pharyngitis, 1 to 5 weeks
EPIDEMIOLOGY (Philippine Statistics) (average: 3 weeks) before the onset of
 Prevalence Rate 0.1-22/1000 symptoms is common. The latent period
 In 1000 children, there will be 1-22 may be as long as 2-6 months (average:
children with RHD. 4months) in case of isolated chorea.
 It accounts for 40% of total cardiac
admissions at Philippine Heart 1. Pallor, malaise, easy fatigability, and other
Center history such as epistaxis (5%-10%) and
 Recurrence/ Streptococcal Infection 14.6% abdominal pain may be present.
2. Family history of rheumatic fever is
There is recurrence because of the patient’s failure to
frequently positive.
follow secondary prevention or the prophylaxis.

CLINICAL COURSE
PREDISPOSING FACTORS
1. Family History of Rheumatic Fever
2. Low socio-economic status
3. Age between 6-15 years (with peak
incidence at 7-8 years of age)
Ideally, you don’t see a patient 5 years old and below
with bouts of rheumatic fever, but in medicine there are
always exceptions. Although, it would be unwise to
diagnose a 6-month old with rheumatic fever.
1. Acute Rheumatic Fever
2. Chronic Rheumatic Fever
3. Subclinical Course of Rheumatic Fever
Subclinical course are those patients who would present
with heart murmurs, positive ASO titers, thickening of
the heart valves, mitral regurgitation, aortic stenosis or
aortic regurgitation. But upon taking the history, the
patient would deny having pharyngitis. In other words,
the patient is negative. So there was a clinical infection,
there was Strep Pharyngitis, but it did not manifest in
the patient. This is called Silent Pharyngitis.

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SOME CLINICAL CHARACTERISTICS OF THE”STREP” THROAT COMPARED WITH THOSE OF A
NON-STREP THROAT (USUALLY VIRAL INFECTION)

CLINICAL CHARACTERISTICS STREP THROAT NON-STREP THROAT

AGE 5-15 Years ( Most Common) All ages
MODE OF ONSET Sudden More Gradually
INITIAL SYMPTOMS Sore Throat with Pain While Swallowing Mild Sore Throat
FEVER High (Over 39ºC) Not so High (low grade)
Redness, hyperemia, edema and Redness of the pharynx
exudates (yellow flecks) of the pharynx

APPEARANCE OF THE THROAT Enlargement of the tonsils with exudates

Hyperemia, edema and punctuate

hemorrhages in soft palate
Tenderness of the interior cervical lymph Cough +
nodes Hoarseness +
Watery nasal
OTHER SIGNS Scabby erosions on the edge of the secretion +
nostrils Conjunctivitis

Clinical picture of scarlet fever

Always differentiate Strep Pharyngitis from Viral Pharyngitis. Usually, the initial manifestation of Strep Pharyngitis is
tonsillitis. 80% of tonsillitis in children is of viral origin so there is no need to give antibiotics because it is self-limiting.
But, if there is presence of yellow flecks or exudates, it is most likely Strep Pharyngitis.

GUIDELINES FOR THE DIAGNOSIS OF What is the most common valvular defect in CHILDREN?
INITIAL ATTACK OF RHEUMATIC Mitral REGURGITATION
JONES’ CRITERIA What is the most common valvular defect in ADULTS?
 Formulated by Thomas Duckett Jones in Mitral STENOSIS
1944 which is use as a guide in diagnosing
Where is Mitral Regurgitation Murmur appreciated?
first attack of rheumatic fever At the APEX. It is heard as lab-sshh-dub, between S1 and
 Revised and modified several times and last S2. It is a pansystolic murmur radiating to the back.
updated in 1992
3. Pericarditis (friction rub, pericardial
MAJOR JONES MANIFESTATIONS effusion, chest pain and ECG changes)
 Carditis PE Finding of Pericardial Effusion? Muffled heart sounds
 Polyarthritis
 Chorea 4. Cardiomegaly on chest x-ray is
 Erythema Marginatum indicative of pancarditis or CHF
 Subcutaneous Nodules 5. Signs and symptoms of Congestive
Heart Failure such as:
Mnemonic: Clinico Pathologic Conference Every Saturday a. Cough
b. Dyspnea
CARDITIS c. Orthopnea
 Occurs in 50-75% of patients with Acute d. Gallop rhythm
Rheumatic Fever e. Distant heart sound
 It is potentially the most serious f. Cardiomegaly
cause of morbidity and accounts for g. Hepatomegaly
most of the mortality encountered
during the acute stage of the disease
 Signs of carditis include some or all of the
following in the increasing order of
severity:
1. Tachycardia (out of proportion for the
degree of fever)
With every 1-degree increase in fever, there should be a
10-beat-per-minute increase in the heart rate.

2. Heart murmur of valvulitis (caused by

MR and/or AR), mitral insufficiency is Cardiomegaly with Pulmonary Congestion
the hallmark of rheumatic carditis

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POLYMIGRATORY ARTHRITIS
 most common (75%) of the major
manifestation but it is the least
specific and is often the major cause
of misdiagnosis of ARF
 usually involves large joints (e.g. knees,
ankles, elbows, wrist)
 often more than one joint, either
simultaneously or in succession, and is
involve with a characteristic migratory
nature of the arthritis
 active inflammation in the joint,
manifested by severe pain, swelling,
erythema and warmth
 self- limiting without residual damage,
lasting 2-3 weeks
 exhibits dramatic response to ASA within
48-72 hours
ERYTHEMA MARGINATUM
 occurs in fewer than 10% of patients
with acute rheumatic fever
 characteristic non-pruritic, serpiginous or
annular erythematous rashes are most
prominent on the trunk and the inner
proximal portion of the extremities; they
are never seen on the face
 rashes are evanescent, disappearing on
exposure to cold and reappearing after a
hot shower or when the patient is covered
with a warm blanket
 seldom are detected in air-conditioned
hospital rooms
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Mau Manzana, Anonymous
Formatting: Gladys Dianne Hulipas
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SUBCUTANEOUS NODULES
 found in 2% to 10% of cases, particularly
in those with recurrences
 measures 2cm in diameter
 they are usually found symmetrically,
singly or in clusters, on the extensor
surfaces of both large and small joints, over
the scalp, or along the spine
SYDENHAM’S CHOREA
 found in 15% of patients with acute
rheumatic fever
 begins with emotional lability and
personality changes, and these soon are
replaced by loss of motor coordination
(“twice punished child”)
 may be related to dysfunction of basal
ganglia and cortical neuronal
components.
So for the Major Jones Criteria, Carditis and
Polymigratory Arthritis are the common ones, while
erythema marginatum, chorea and subcutaneous nodules
are rare.
MINOR JONES’ MANIFESTATIONS
CLINICAL FINDINGS
 Arthralgia – refers to joint pains without
objective changes of arthritis (all the signs of
inflammation [rubor, dolor, tumor, calor] are
present in arthritis)
 Fever – core body temperature >38C,
sometimes for weeks
LABORATORY FINDINGS
 Elevated acute phase reactants:
 Elevated Erythrocyte Sedimentation
Rate
 (+) C-Reactive Protein
 Prolonged PR interval
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If Rheumatic Fever is being considered as diagnosis, the
only laboratory tests to be requested are ASO titer, ESR
and CRP. ESR and CRP should be elevated and on ECG
there should be prolongation of PR interval.
How to determine if the PR interval is prolonged?
If the interval is >0.20 which means there is more than
five steps from the beginning of P to the beginning of the
QRS complex.
What is the significance of the ASO titer?
The ASO titer signifies that the patient had Strep
infection a few weeks ago. In medicine, a significant ASO
titer is 255 units, but in pediatrics, it is 300 to 350 units. In
the absence of other manifestations, even if the ASO
titer is high, it is not diagnostic of rheumatic fever. ASO
titer is normal if there is intake of antibiotics.
SUPPORTING EVIDENCE OF ANTECEDENT
GROUP A STREPTOCOCCAL INFECTION
 positive throat culture
 positive rapid streptococcal antigen test
 elevated or rising streptococcal antibody
titer
 ASO significant titer is >330 Todd units
and present in 80%; it is indicative for
streptococcus, and a high titer in the
absence of other manifestations is not
diagnostic of rheumatic fever.
 The presence of two major
manifestations OR of one major and
two minor manifestations plus a
supporting evidence of a preceding group
A streptococcal infection indicates a high
probability of acute rheumatic fever.
ACUTE RHEUMATIC FEVER
 Acute phase reactants are not specific but
indicate acute inflammation
 ESR is false (-) in congestive heart failure
and anemia
 Anti-inflammatory agents suppress ESR
and CRP result
 Prolonged PR interval is not a sign of
acute carditis and is functional and
reversible
The P-R interval consists of the P wave and the PR segment
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Mau Manzana, Anonymous
Formatting: Gladys Dianne Hulipas
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EXCEPTION TO THE JONES’ CRITERIA
INCLUDES THE FOLLOWING SPECIFIC
SITUATIONS
 Chorea may occur as the only
manifestation of rheumatic fever.
 Indolent carditis may be the only
manifestation of rheumatic.
 Occasionally, patients with rheumatic
fever recurrences may not fulfill the
Jones criteria.
Jones criteria are only used for first attack of Rheumatic
Fever. (Remember this!)
 A history of rheumatic fever or
rheumatic heart disease is no longer
considered a minor manifestation.
 The absence of evidence of an
antecedent group A streptococcal
infection is a warning sign against acute
rheumatic fever (except when chorea is
present).
THE FOLLOWING TIPS HELP IN
APPLYING THE JONES CRITERIA
 Two major manifestations always are
stronger than one major plus two minor
manifestations.
 Arthralgia or a prolonged PR interval
cannot be used a minor manifestation in
the presence of arthritis or carditis,
respectively.
 The vibratory innocent (Still’s)
murmur frequently is misinterpreted as a
murmur of MR and thereby is a frequent
cause of misdiagnosis (or overdiagnosis)
of acute rheumatic fever.
o Editor’s note: The murmur of MR is a
regurgitant-type systolic murmur, but
the innocent murmur is low-pitched and
an ejection type
 The possibility of early suppression of full
clinical manifestation should be sought
during the history taking. Subtherapeutic
doses of aspirin or salicylate containing
analgesics (e.g. Ascriptin, Advil, Ponstan)
may suppress full manifestations.
Because antibiotics suppress the full manifestation of
rheumatic fever, DO NOT consider requesting for
laboratory tests (i.e. ESR, CRP and ASO).
LABORATORY EXAMINATIONS
 Acute phase reactants : ESR, CRP
 Streptococcal infection: ASO titer, throat
culture
 Cardiac status: ECG, chest x-ray and two-
dimensional echocardiography
 There is no laboratory test available at
present that allows either by itself or in
conjunction with other test the specific
diagnosis of Acute Rheumatic Fever.
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 ROLE OF ECHOCARDIOGRAPHY IN ACUTE DURATION OF SECONDARY PROPHYLAXIS
RHEUMATIC FEVER AND RHEUMATIC CATEGORY DURATION
HEART DISEASE RHEUMATIC FEVER Minimum of 5 years or until 21
 It assesses the degree of myocardial WITHOUT CARDITIS years, whichever is longer
contractility and measures the ejection RHEUMATIC FEVER
fraction. WITH CARDITIS BUT Minimum of 10 years or well into
 It assesses the presence and degree of NO RESIDUAL HEART adulthood, whichever is longer
mitral and aortic regurgitation. DISEASE
(no valvular disease)
 It measures ventricular dimension and
RHEUMATIC FEVER
quantitates regurgitation. At least 10 years since the last
WITH CARDITIS AND
 It confirms the presence of pericardial RESIDUAL HEART
episode and at least until 40
effusion and quantitates the presence of years, sometimes lifelong
DISEASE
prophylaxis
fluid on the pericardial space. (persistent valvular
 It differentiates valvular insufficiency due disease)
to acute rheumatic fever from mitral valve Documented by Echocardiography (Remember this table!)
prolapse and bacterial endocarditis. Dr. Lapak’s cut-off: 16 years old
If a patient is below 16 years old, injections are given until 21
MANAGEMENT years old. If a patient is above 16 years old, injections are
PRIMARY PREVENTION given for 5 years.
 Eradication of streptococcal pharyngitis
and prevention of the development of Well into adulthood: after 40 years old
rheumatic fever How to monitor the valves? Do a 2D echo yearly.

 50 –100 mg/kg/day for 10 ANTI-INFLAMMATORY TREATMENT

ORAL PENICILLIN
days
ARTHRITIS
ERYTHROMYCIN  40 –50 mg/kg/day for 10 days
 1.2 million units as single  75 –100 mg/kg/day for 1 –2
dose for patients more than ACETYLSALICYLIC ACID weeks
BENZATHINE (ASA)  65 mg/kg/day for 6 weeks
27 kg
PENICILLIN
 600,000 units single dose for then taper
patients less than 27 kg
 RF can be prevented if treatment of GAS CARDITIS
pharyngitis is started within 9 days of
WITHOUT  ASA 10mg/kg/day x 2 weeks
onset and continued for 10 days.
CARDIOMEGALY  65 mg/kg/day for 6-8 weeks
 Prednisolone 2 mg/kg/day for
SECONDARY PREVENTION OF RHEUMATIC 2-4 weeks
FEVER OR PREVENTION OF RECURRENCES
CARDIOMEGALY OR CHF
 Secondary prevention will be Add ASA on the final week of
recommended for rheumatic fever patients prednisolone and continue for 6-
of all ages, who have had one or more 12 weeks
attacks of rheumatic fever. Precautions in using prednisolone: patient is prone to
 To prevent second and recurrent attacks infection, moon facies, increase in appetite and increase in
of rheumatic fever body hair.
If patient will take prednisone for more than 2 weeks, the
BENZATHINE BENZYL 1.2 million units every 21
patient will be immunocompromised. Isoniazid is a
PENICILLIN (ZALPEN OR days
prophylactic antibiotic to prevent organism from entering the
PENADUR)
body. Only stop the isoniazid when patient stops taking
PENICILLIN V 250 mg BID
prednisone.
ERYTHROMYCIN 250 mg BID
If a patient is taking prednisone for carditis, when you start
Always do skin test. Even if the patient has been injecting tapering the drug, overlap with aspirin. Likewise, if patient is
Penadur for a long time, anaphylactic reactions may still started with aspirin, don’t just stop taking the aspirin because
occur, which is why injections must be done in a hospital there is a tendency to have rebound inflammation if it is not
setting. tapered.

Why 21 days? INDICATION FOR ANTI-INFLAMMATORY

Because studies have shown that the antibiotic only lasts TREATMENT
for 21 days in the body.
Rheumatic fever, once diagnosed by appropriate
If a patient missed an injection, possible infection may
occur, leading to another attack -- thus further destroying
criteria, is considered clinically active if anyone of the
the heart valves. following features is found:
1. Joint symptoms
There are high rates of recurrent attacks with oral 2. New organic murmurs
penicillin because bioavailability of drug is affected by 3. Changing heart size
food. 4. Congestive heart failure (in the absence of
long-standing severe valvular disease)
5. Subcutaneous nodules
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 6. A sleeping pulse rate greater than
100/minute
7. Erythema marginatum
8. Chorea
9. A positive test for C-reactive protein
10. Unexplained fever with rectal temperature
of 100.4°F for at least 3 consecutive days.
MITRAL REGURGITATION
 Defined as a leakage of blood from the
left ventricle in to the left atrium during
systole. It is caused by various
mechanisms related to structural or
functional abnormalities of the mitral
apparatus, adjacent myocardium, or both.

CHOREA
 Bed rest and avoidance of stress
 Severe symptoms: Phenobarbital 15 –30
mg every 6 –8 hours
 Haloperidol 0.5 mg gradually increased to
2 mg every 8 hours

FOR PATIENTS WITH SIGNIFICANT

CARDITIS
 Digoxin (Lanoxin)
 0.04 mg/kg/day in 4 divided doses
then maintain bid.
 Diuretic (Furosemide in combination with
This is the typical drawing of a heart with mitral
Potassium or Spironolactone) regurgitation. Ideally, there should be no blood regurgitating
from the left ventricle to the aorta. If there is mitral
Who are patients with significant carditis? Those that have regurgitation, because the mitral valve is inflamed, it will
severe mitral regurgitation or severe aortic insufficiency. shorten and not fully close during systole. There is an
opening so the blood will go back to the left atrium.
Diuretics are given to decrease the preload. To put it simply,
if a patient has severe MR or AR, there is a lot of blood in the
left ventricle, which will stretch the left ventricle and lead to
congestive heart failure. If diuretics are given, the total blood
volume is decreased, which is beneficial in relieving the
congestion.

RHEUMATIC HEART DISEASE

 Most common valve involved: MITRAL
VALVE
 Most common valvular pathology:
MITRAL REGURGITATION alone or in
combination with AORTIC
REGURGITATION
Mitral STENOSIS: diastolic rumble at the apex that radiates to
the back
Mitral REGURGITATION: Pansystolic murmur radiating to the
back

Mitral stenosis is more life-threathening. Patients are given

laxatives to avoid using pressure because patient may go into
arrest or develop pulmonary edema.

FOR MODERATE AORTIC REGURGITATION

AND MITRAL REGURGITATION
 Lanoxin
 ACE inhibitor (Captopril)
 Diuretic
Digoxin is used to increase myocardial contractility in an effort
to increase the cardiac output.
Mitral Regurgitation
ACE inhibitors inhibit the conversion of Angiotensin I to
Angiotensin II. If angiotensin I is inhibited to form angiotensin
II, there will be vasodilatation.

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 PATHOPHYSIOLOGY AND NATURAL Wide pulse pressure occurs when there is a big difference
HISTORY between the systolic and diastolic pressures. A normal pulse
pressure is usually between 20-30 (e.g. 90/60, 100/70) but if
 Significant MR leads to volume overload of
there is wide pulse pressure, systolic blood pressure may be 130
the left ventricle, because it has to and the diastolic pulse pressure would be 0. The wider the
accommodate both the stroke volume and pulse pressure, the more severe the AR.
regurgitant volume with each heartbeat.
To compensate, the left ventricle dilates
Please memorize this!
and becomes hyperdynamic. In acute
A rapid and forceful
severe MR, the left atrial and pulmonary
CORRIGAN’S PULSE distension of the arterial pulse
venous pressures increase quickly, leading
with a quick collapse.
to pulmonary congestion and pulmonary
Bobbing of the head with
edema.
DE MUSSET’S SIGN each heartbeat (like a bird
 In chronic MR, a gradual increase in left
walking)
atrial size and compliance compensate so
MULLER’S SIGN Visible pulsations of the uvula
that left atrial and pulmonary venous
Capillary pulsations seen on
pressures do not increase until late in the
QUINCKE’S SIGN light compression of the nail
course of the disease. Progressive left
bed
ventricular dilation eventually leads to
Systolic and diastolic sounds
an increase in afterload, contractile TRAUBE’S SIGN heard over the femoral artery
dysfunction, and heart failure. Left atrial (“pistol shots”)
enlargement predisposes the patient to Gradual pressure over the
atrial fibrillation and arterial DUROZIEZ’S SIGN femoral artery leads to a
thromboembolism. In long-standing systolic and diastolic bruit
MR, patients may develop pulmonary Popliteal systolic blood
hypertension and right-sided heart pressure exceeding brachial
failure. systolic blood pressure by 60
HILL’S SIGN
Sildenafil is the drug of choice for pulmonary hypertension. mmHg or greater (most
sensitive sign for aortic
SIGNS AND SYMPTOMS regurgitation)
 Patients with chronic, severe mitral SHELLY’S SIGN Pulsation of the cervix
regurgitation may remain asymptomatic ROSENBACH’S SIGN Hepatic pulsations
for years because the regurgitant volume Visible pulsations of the
BECKER’S SIGN
load is well tolerated as a result of retinal arterioles
compensatory ventricular and atrial GERHARDT’S SIGN Pulsation of the spleen in the
dilation. When symptoms do develop, the (aka SAILER’S SIGN) presence of splenomegaly
most common are dyspnea, fatigue, a decrease in diastolic blood
orthopnea, paroxysmal nocturnal pressure of 15 mmHg when
MAYNE’S SIGN
dyspnea, and palpitations caused by atrial the arm is held above the
fibrillation. head (very non-specific)
 Acute severe MR, as occurs with chordal systolic contraction and
LANDOLFI’S SIGN
rupture or papillary muscle rupture, is diastolic dilation of the pupil
almost always symptomatic because the
sudden regurgitant volume load in the GENERAL GUIDELINES FOR BED REST
non-dilated left ventricle and atrium leads AND AMBULATION
to pulmonary venous hypertension and
ARTHRITIS MINIMAL MODERATE SEVERE
congestion.
ALONE CARDITIS CARDITIS CARDITIS
 The characteristic finding in a patient BED REST
with MR is a blowing holosystolic 1-2 weeks 2-3 weeks 4-6 weeks 2-4 months
murmur heard best at the cardiac apex. INDOOR AMBULATION
When ventricular enlargement is present, 1-2 weeks 2-3 weeks 4-6 weeks 2-3 months
the apical impulse may be diffuse and OUTDOOR SCHOOL ACTIVITY
laterally displaced, and a third heart 2 weeks 2-4 weeks 1-3 months 2-3 months
sound may be heard. FULL ACTIVITY
After 6-10 After 3-6 Variable
weeks weeks
AORTIC REGURGITATION PERIPHERAL
SIGNS
DISCLAIMER: It appears that there has been a mix-up in the
 The peripheral signs of aortic regurgitation
subtitles of the table provided in the ppt. I just revised it.
are mostly due to the high-flow state,
large stroke volume and wide pulse
pressure seen in aortic regurgitation

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 BACTERIAL ENDOCARDITIS PROPHYLAXIS FOR RF/RHD
DENTAL, ORAL, OR RESPIRATORY TRACT OR ESOPHAGEAL PROCEDURES
 Standard General Prophylaxis: Amoxicillin 50 mg/kg PO 1 hour before procedure
 Unable to take oral medications: Ampicillin 50 mg/kg IM or IV 30 minutes before procedure
 Allergic to Penicillin: Clindamycin 20 mg/kg po 1 hour before procedure

Patient’s with acyanotic heart disease, prophylaxis is not recommended anymore. It is only recommended for patients with
cyanotic heart disease and for those patients who underwent post-operative heart surgery.

Prophylaxis is given 1 hour before the procedure if per orem because it takes time for the antibiotics to circulate. If a tooth
is to be extracted, there should be high levels of amoxicillin.

REVIEW QUESTIONS:
1. What are the MAJOR Jones’ criteria?
2. What are the MINOR Jones’ criteria?
3. Differentiate PRIMARY from SECONDARY prevention of Rheumatic Fever.
4. For how long will you give secondary prophylaxis to a patient who has rheumatic fever with carditis and residual
valvular disease?
5. What is the most sensitive sign for aortic regurgitation?
6. What do you call that murmur which is frequently misinterpreted as a murmur of MR and often leads to a
misdiagnosis?
7. What is the drug of choice for pulmonary hypertension?
8. Suppose that your patient is allergic to penicillin. What do you give instead for bacterial endocarditis prophylaxis?
9. What are the three medications given for moderate AR and MR?
10. What would indicate a high probability of acute rheumatic fever?

BONUS: What does John 3:16 say in the Bible?

CONCLUSION
There is still hope for rheumatic fever patients to have normal hearts if one is aggressive with secondary
prophylaxis regimen.

-END-

TO GOD BE THE GLORY!!!

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REMARKS In all things, may God be honored! God bless, Batch 2016! Make your parents proud  <3 -Editor
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Dr. Lapak’s Tips for Junior Internship:

1. Talk To God.
2. Eat, survive and be healthy.
3. Groom yourself.
4. Read and be prepared. Know the mission/vision and the curriculum of the department you’re rotating on.
5. Have a complete set of paraphernalias.
6. Respect your mentors and learn from them.
7. Treat your patients as your relatives.
8. Have a healthy relationship with your groupmates and hospital staff and employees.
9. Cut the rumors.
10. Have time for yourself, family and loved ones.

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