A 41 year old carpenter presented with 5 months  of progressive shortness of breath during strenuous activities.  Chest pain and   palpitations often occurred with exertion.  Nocturnal attacks of breathlessness occurred 5 times in the last month.  During these attacks, he was unable to lie flat.   The  patient  had no metabolic disease,  and recently had no change  in weight.   At age 9 he was diagnosed with rheumatic fever.

Upon examination he was found to have  typical findings  of congestive heart failure due to underlying mitral valve stenosis.   No evidence of bacterial endocarditis was found.   The patient  was treated with digoxin, anticoagulants, and diuretics.  Cardiac surgery had been considered, but  was postponed due to  improved exercise  tolerance on the medical regimen.   In order to prevent the onset of subacute bacterial endocarditis, antibiotic prophylaxis was recommended by the cardiologist.