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Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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Page 1: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

Cardiology Conference

Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo

December 22, 2010

Page 2: 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

Page 3: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 4: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 5: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 6: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 7: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 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

Page 8: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

Family History

• (+) Rheumatic Heart Disease – maternal grandmother• (-) HPN• (-) Diabetes Mellitus• (-) Pulmonary Tuberculosis• (-) Allergies

Page 9: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 10: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 11: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 12: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 13: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 14: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 15: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 16: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

Clinical Impression

Congenital Heart Disease

Pneumonia

Page 17: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

Differential diagnosis

CHD

Cyanotic Non-cyanotic

Page 18: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 19: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

VENTRICULAR SEPTAL DEFECT

Page 20: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

Ventricular Septal Defect

• most common ACHD (25%)• SYNONYMS

* Roger’s disease

* Interventricular septal defect

* Congenital cardiac anomaly

Page 21: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 22: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

Anatomical Classification

• Membranous/ perimembranousVSD– Most common CHD

(males>females)• • Muscular VSD

– “Swiss cheese” VSD• Supracristal VSD

– Least common

Page 23: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 24: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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

Page 25: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

Methods

• Study design: prospective multi-centre study

• Zurich, Switzerland; May 2003 to May 2004

• Population: infants above 35 weeks of gestation (n=3,262)

Page 26: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

Methods

Page 27: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

Results

Page 28: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

Results

Page 29: Cardiology Conference Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo, Geronimo December 22, 2010

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