Abstract
A 20-year-old man was referred to us for assessment of a 1 year history of dyspnoea on exertion. At the age of 9 years, he had had two episodes of migratory polyarthritis suggestive of rheumatic fever. Cardiovascular examin ation showed a grade III/VI pansystolic murmur at the apex (see video). We noticed he had painless, correctable deformities of his hands and feet (fi gure A and B). He did not know his hands were deformed. His joints were enlarged but there was no evidence of active joint infl ammation or functional impairment, and no subcutaneous nodules. The erythro cyte sedimentation rate Lancet 2013; 381: 2108
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