📋 MOCK OSCE · FCPS, MCPS, MD PAEDIATRICS ⏱ 10 min · MITRAL REGURGITATION (RHD)

Mitral Regurgitation · Rheumatic

Candidate task: perform focused cardiovascular examination on a child with suspected rheumatic mitral regurgitation.
Then discuss differential diagnosis, investigations, management & follow‑up.
Pre‑exam Protocol
⏤ · Wash, Warm, Introduce, Position, Expose, Approach ▾

Standard pre‑examination protocol – must be demonstrated:

🖐 Wash hands with sterilizing solution.
🔥 Warm hands and stethoscope.
👋 Introduce yourself to child & parent.
🧍 Position child: supine, sitting, then left lateral (to accentuate mitral murmurs).
👕 Exposure — chest fully exposed, warm environment.
➡️ Approach from the right side.
✔ CPSP marker: Pre‑exam Protocol is observed and scored.
1. Clinical Examination (≈6 min)
02 General Look (Inspection from end of bed) ▾

Key observations:

  • Colour: pallor (anaemia – chronic disease), cyanosis (late).
  • Respiratory rate: tachypnoea (heart failure – if severe MR).
  • Precordial bulge: chronic LV enlargement.
  • Nutritional status: failure to thrive (severe MR).
  • Dysmorphic features: none specific.
  • Activity: exercise intolerance, fatigue, dyspnoea.
👁 Red flags: apical holosystolic murmur + displaced apex + previous history of rheumatic fever → rheumatic MR.
03 Precordium & Cardiovascular Examination ▾

Systematic cardiovascular exam:

  • Inspection: scars (previous surgery), chest asymmetry, apex beat visible.
  • Palpation: apex displaced laterally and downwards (LVH), apical thrill (systolic).
  • Auscultation: S1 soft (if severe), S2 normal or accentuated P2 (if pulmonary hypertension), apical holosystolic murmur radiating to axilla.
  • Additional: mid‑diastolic rumble (increased mitral flow), S3 (if severe).
  • Positional changes: left lateral decubitus → murmur accentuated.
🔍 Key: apical holosystolic murmur + displaced apex + radiation to axilla → mitral regurgitation.
04 General Physical Exam (Hands → Face → Chest → Limbs) ▾

Systematic examination:

  • Hands: clubbing (if cyanotic heart disease), capillary refill time, splinter haemorrhages.
  • Face: mucous membrane colour (pallor), dental caries (SBE risk).
  • Chest: auscultate lung fields (crackles – heart failure).
  • Pulses: normal volume (unless heart failure).
  • Blood pressure: 4‑limb BP (exclude coarctation).
  • Joints: signs of acute rheumatic fever (arthritis, nodules, erythema marginatum).
  • Lower limbs: oedema (right heart failure – late).
📏 Anthropometry: weight, length – plot growth.
05 Developmental Assessment & Associated Signs ▾

Assess:

  • Motor milestones: may be delayed (chronic heart failure).
  • Growth: failure to thrive (severe MR).
  • Associated signs of RHD: previous history of rheumatic fever, chorea, arthritis.
  • Skin: erythema marginatum, subcutaneous nodules (acute RF).
  • Neurological: Sydenham chorea (if acute RF).
🧠 Key: MR + history of acute rheumatic fever (Jones criteria) → RHD.

📋 Case Presentation – (fill in during exam)

This is a _____-year-old _____ child, referred for _____ (murmur / dyspnoea / heart failure). On examination, the child appears _____ (well/unwell/lethargic), with _____ (tachypnoea / pallor / oedema). Precordial inspection: _____ (bulge / scar). Palpation: _____ (apex displaced / thrill). Auscultation: S1 _____ (soft), S2 _____, murmur _____ (apical holosystolic) radiating to _____ (axilla). Additional: mid‑diastolic rumble _____ (present / absent). Pulses: _____. BP: _____. Growth: weight _____ percentile, length _____ percentile. Associated signs: _____.

2. Viva Discussion (≈4 min)
06 Viva · Differential, Investigations, Management, Follow‑up ▾
🔹 Differential Diagnosis

• Rheumatic mitral regurgitation – apical holosystolic murmur
• Mitral valve prolapse – mid‑systolic click + late systolic murmur
• Congenital mitral cleft (AVSD) – holosystolic murmur
• Infective endocarditis – acute onset, fever, vegetations
• Dilated cardiomyopathy – MR secondary to LV dilation
• Functional MR – LV dysfunction, annular dilation
• VSD – holosystolic murmur at LLSB
• Tricuspid regurgitation – LLSB, increases with inspiration
• Aortic stenosis – ejection click, radiation to carotids

🔹 Investigations – Diagnosis

• Echocardiography: 2D + Doppler – valve anatomy, regurgitant jet, LV size and function.
• Chest X‑ray: cardiomegaly (LV, LA), pulmonary venous congestion.
• ECG: LVH, LA enlargement (bifid P waves), AF (late).
• Cardiac catheterisation: if PVR assessment needed, or for surgery planning.
• BNP: heart failure severity.

🔹 Investigations – Aetiology

• ASOT / anti‑DNAse B: evidence of recent streptococcal infection.
• Jones criteria: to confirm acute rheumatic fever.
• Blood cultures: if infective endocarditis suspected.
• CRP / ESR: elevated in acute RF.

🔹 Investigations – Exclude Others

• Echocardiography: rule out congenital mitral cleft, MVP, AVSD.
• CXR: differentiate from VSD (LVH) and ASD (RVH).
• ECG: differentiate from MVP (normal ECG).

🔹 Investigations – Rule Out Complications

• Echocardiography: pulmonary hypertension, LV dysfunction, vegetations.
• Cardiac catheterisation: PVR, mitral valve area (if stenosis).
• Holter: arrhythmias (AF, VT).
• Blood cultures: if infective endocarditis suspected.

🔹 Management – Across Organ Systems

Acute RF

Penicillin, aspirin/corticosteroids (for carditis), bed rest.

Heart Failure

Diuretics (furosemide), ACE inhibitors, digoxin if refractory.

Afterload Reduction

ACE inhibitors (captopril, enalapril) – reduce regurgitant volume.

Nutrition

High‑calorie feeds if failure to thrive.

Secondary Prophylaxis

Benzathine penicillin 1.2 MU monthly (for ≥10 years or until age 40).

Infective Endocarditis

Prophylaxis recommended for prosthetic valves and previous endocarditis.

Surgical

Valve repair (preferred) or replacement (if severe, symptomatic, LV dysfunction).

Genetic Counselling

Not applicable (acquired).

📈 Prognosis

  • Mild MR: excellent prognosis; may regress.
  • Moderate MR: monitor for LV dilation; may require surgery.
  • Severe MR: risk of LV dysfunction, AF, heart failure.
  • Post‑valve repair: excellent outcomes.
  • Secondary prophylaxis: reduces recurrence of RF.

📋 Follow‑up Schedule

  • Mild MR: annual cardiology review.
  • Moderate MR: 6‑12 monthly with echocardiography.
  • Severe MR: 3‑6 monthly; consider surgery.
  • Post‑surgical: 6‑12 monthly for 1‑2 years, then annually.
  • Lifelong: if prosthetic valve or residual disease.
💡 Examiner expectation: logical differential (valvular vs functional), systematic investigation (diagnosis → aetiology → exclude others → complications), and a management plan covering acute RF, secondary prophylaxis, heart failure, and surgical referral. Know the Jones criteria and the importance of penicillin prophylaxis.
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Mock OSCE · Mitral Regurgitation with Rheumatic Heart Disease · Based on Wyne‑Harris, Nelson & Pediatric Clinical Advisor