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Cardiology Conference
Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo
December 22, 2010
C.F. 2 months old / maleCC: Fever
Gestation
al
History
•16 y/o primigravid G1P1 (1001)
• Prenatal check-up (?) - ferrous sulfate (unrecalled dose and duration of intake)
•No viral exposure• 1 month of
pregnancy – (+) alcohol and smoking
• 4 month of pregnancy – (+) UTI – completed cephalexin 500mg/cap q6 and amoxicillin 500mg/cap q8 x 7 days
Birth Histo
ry
•Full term•3.2 kg (N 3-3.5
kg) via NSD, singleton, cephalic presentation at a local hospital
•No complications•APGAR not
known
C.F. 2 months old / maleCC: Fever
Feeding
History
•Mixed breastfeeding and milk formula
•No feeding difficulty
•(-) cyanosis
Developmental
History
•No regular check-up
•At par with development
C.F. 2 months old / maleCC: Fever
2 days PTA
• Incessantly crying and irritable
•2 episodes of vomiting of previously ingested food, ~1/2 cup/episode
•(-) cyanosis, good appetite
1 day PTA
•Crying and irritability persisted
•Fever 38°C, colds with whitish nasal discharge and difficulty in breathing
•Health center – 0.65% NaCl drops 1-2 drops/nostril q8 and paracetamol 100mg/mL 0.5mL prn for fever
Few hour
s PTA
•Symptoms persisted
•ADMISSION
Review of Systems
• General: (-) noticeable weight loss• Cutaneous: (-) rashes, (-) discoloration • HEENT: (-) ear discharge, (-) epistaxis, (-) gum bleeding• Respiratory: refer to HPI• Cardiovascular: refer to HPI• GI: (-) diarrhea, (-) constipation• GUT: yellow urine, (-) edema of the hands and feet• Extremities: (-) swelling, (-) joint swelling • Nervous/Behaviour: (-) tremors, (-) convulsions • Hematopoietic: (-) pallor, (-) easy bruisability
Immunization History
• Received the following at a local health center:• BCG 1• Hepatitis B 1• DTP 1• OPV1
– Next dose due on December 27, 2010
Family Profile
Age/ Gender
Relation to the patient
Educational Attainment
Occupation Health
P. F 17 y/oMale
Father 3rd year high school
Student Healthy
C. R 16 y/oFemale
Mother High School graduate
Housewife Healthy
A.C 63 y/oMale
Grandfather 2nd year college
Government employee
Healthy
Y.C 54 y/oFemale
Grandmother 2nd year college
Housewife (+) RHD
Family History
• (+) Rheumatic Heart Disease – maternal grandmother• (-) HPN• (-) Diabetes Mellitus• (-) Pulmonary Tuberculosis• (-) Allergies
Socioeconomic and Environmental History
• Four bedroom house made of wood and concrete• Well lit and well ventilated• Garbage is collected daily, no segregation • Purified water from a water refilling station. • Baby bottles also sterilized• Stray cats• Second hand smoke
Physical Examination
• General Survey: awake, alert, in respiratory distress with alar flaring, ill looking, well-nourished, well-hydrated
• Vital Signs: HR 140 bpm, RR 70 cpm Temp 36.0 °C Wt 4.7 kg (z=below 0 normal) Ht: 49 cm (z= below -3 severely stunted) BMI: 19.58 (z= above 2 overweight)
• Head circumference 37 cm, chest circumference 36 cm, abdominal circumference 40 cm
• Skin: Warm, moist skin, pink in color, good skin turgor, no rashes, no jaundice
Physical Examination
• HEENT: normocephalic, anterior fontanel open, symmetric head, (-) scalp lesions, symmetric face; Eyeballs not sunken, pink palpebral conjunctiva, anicteric sclerae, pupils 2-3 mm ERTL; Midline nasal septum, (+) whitish nasal discharge; Moist buccal mucosae, nonhyperemic posterior pharyngeal wall; Supple neck, (-) palpable lymph nodes
Physical Examination
• Lungs/Chest: Symmetric chest expansion, (+) subcostal retractions, (+) crackles on both upper lung fields
• Cardiovascular: adynamic precordium, no precordial bulge, (-) Harrison’s groove, (+) holosystolic murmur at the lower left parasternal area grade 3/6
• Abdomen: globular abdomen, normoactive bowel sounds, soft, non tender, no masses
• Spine: midline, (-) sacral dimpling, (-) tufts of hair• Genitalia: Penis 2cm, testes descended bilaterally, no
phimosis, no discharge • Extremities: full peripheral pulses, no cyanosis, no clubbing
Neurologic Examination
• Cerebrum: alert • Cranial nerves: Pupils isocoric, 2-3mm ERTL, (+) direct and
consensual light reflex, (-) gross facial asymmetry, (+) gag reflex• Cerebellum: (-) no involuntary movements• Motor: (-) rigidity, (-) spasticity, (-) Flaccidity• Meningeal Signs: (-) nuchal rigidity, (-) Brudzinski’s, (-) Kernig’s, (-)
tonic neck reflex
Subjective Salient Features
Pertinent Positives Pertinent Negatives
• 2 months old/ Male• Born to a 16 year old primigravid• Prenatal check-up (?)• (+) Smoking and alcohol – 1st month of pregnancy• (+) UTI, treated – 4th month of pregnancy• Full term, NSD
• (+) URTI
• (+) RHD – maternal grandmother
• No viral exposure• No complications at birth• Normal birth weight 3.2 kg• No feeding difficulties• At par with development
• Acyanotic
Objective Salient Features
Pertinent Positives Pertinent Negatives
• Awake, alert, in respiratory distress with alar flaring, ill looking, well-nourished• PR 140 bpm, RR 70 cpm Temp 36.0 °C • (+) whitish nasal discharge• Symmetric chest expansion, (+) subcostal retractions, (+) crackles on both upper lung fields• Adynamic precordium, no precordial bulge, (-) Harrison’s groove, (+) holosystolic murmur at the lower left parasternal area grade 3/6
• Warm, moist skin, pink in color• Full peripheral pulses, no cyanosis, no clubbing
Clinical Impression
Congenital Heart Disease
Pneumonia
Differential diagnosis
CHD
Cyanotic Non-cyanotic
Non-cyanotic
VSD ASD PDA AS PS CoAShortness of breathFast breathingHard breathingPalenessFailure to gain weightFast heart rateSweating while feedingFrequent respiratory infections
Difficulty breathing (dyspnea)Frequent respiratory infections in childrenSensation of feeling the heart beat (palpitations) in adultsShortness of breath with activity
Bounding pulseFast breathingPoor feeding habitsShortness of breathSweating while feedingTiring very easilyPoor growth
Breathlessness with activityChest painFainting, weakness, or dizziness with activityPalpitations
Abdominal distentionCyanosis in some patientsChest painFaintingFatiguePoor weight gain or failure to thrive in infants with severe blockageShortness of breathSudden death
Dizziness or faintingShortness of breathPounding headacheChest painCold feet or legsFailure to thrivePoor growth
VENTRICULAR SEPTAL DEFECT
Ventricular Septal Defect
• most common ACHD (25%)• SYNONYMS
* Roger’s disease
* Interventricular septal defect
* Congenital cardiac anomaly
Ventricular Septal Defect• Physical size of the VSD is a major determinant of the size of
the left-to-right shunt• Restrictive VSD (usually <0.5 cm2) - right ventricular pressure
is normal• Large nonrestrictive VSDs (usually >1.0 cm2)- right and left
ventricular pressure is equalized
Anatomical Classification
• Membranous/ perimembranousVSD– Most common CHD
(males>females)• • Muscular VSD
– “Swiss cheese” VSD• Supracristal VSD
– Least common
The contribution of pulse oximetry to the early detectionof congenital heart disease in
newborns
Romaine Arlettaz, Andrea Seraina Bauschatz, Marion Mönkhoff , Bettina Essers, Urs Bauersfeld
Eur J Pediatr (2006) 165: 94–98
Objectives
• To determine the effectiveness of a pulse-oximetric screening performed on the first day of life for the detection of congenital heart disease in otherwise healthy newborns
• To determine if a pulse-oximetric screening combined with clinical examination is superior in the diagnosis of congenital heart disease to clinical examination alone
Methods
• Study design: prospective multi-centre study
• Zurich, Switzerland; May 2003 to May 2004
• Population: infants above 35 weeks of gestation (n=3,262)
Methods
Results
Results
Conclusion
• Postductal pulse-oximetric screening in the first few days of life is an effective means for detecting cyanotic congenital heart disease in otherwise healthy newborns