Extern Interesting Case

Group 3

7 June 2007

History

Case 5 months-old boyChief complaint :

Dyspnea during breastfeeding 2 months PTA

Present history

2 months PTA, his mother noticed that

her child had dyspnea during breastfeeding.

He took time about 2-3 minutes each feeding

and rested 30 minutes before continue

next feeding.

At the appointment for vaccination,

He was detected that his weight didn’t gain well.

Present history (cont’)

3 wk PTA, He had fever, productive

cough with progressive dyspnea. He

was brought to a private hospital.

Physical examination shown coarse

crepitation both lung, pansystolic murmur

grade III/VI at left parasternal border and liver

was palpated 1 cm. below right costal margin

Present history (cont’)

He was diagnosed pneumonia with

congestive heart failure and was admitted.

Cefotaxime 150 mg IV q 8 hr and Digoxin

0.4 ml oral bid was given for eight days.

After pneumonia resolved, he was referred

to Siriraj hospital.

Other history

Developmental history :Rolling , Palmar grasp, Turn to voice and bubbling.

Food history : Breast feeding , infant formula and supplementary foods.

Drug and Vaccination : Last vaccination at 4 month-old. No drug allergy

Delivery history :Normal labour , term AGA BW 3150 Apgar 9,9

Family history : No congenital heart disease , genetic disease in family

Physical examination

V/S : T. 36.7C, RR 80/min , PR 177/min

BP 71/53 75/47 O2 sat 99 98 90/40 80/53 99 98

BW 4.4 kg (<p3)

Lt. 61 cm (p25) HC 40 cm (p25)

Growth Chart

Weight < p3

Length p25

Physical examination

GA : Alert ,mildly pale ,no jaundice, tachypnea, marked dyspnea (suprasternal, substernal

and subcostal retraction), no central and peripheral cyanosis, no clubbing of finger,

no paradoxical of chest movement, no dysmorphic feature

HEENT : pharynx and tonsils not injected , no thyroid enlargement

Physical examination

RS : Pectus carinatum, normal breath sound,

no adventitious sound

Physical examination

CVS : PMI at 5th Intercostal space just lateral to midclavicular line, Apical heaving. Loud P2

No bounding pulse

- Pansystolic murmur gr III/VI at Left lower sternal border

- Diastolic rumbling murmur gr II at apex

Physical examination

Abdomen : soft, not tender, liver 2 cm Below right costal margin , smooth surface rubbery consistency. spleen not palpable

NS : active, symmetrical movement,

normal muscle tone, good motor power

Problem list

1. Dyspnea during breastfeeding for 2 months

2. Poor weight gain

3. Tachypnea , tachycardia , hepatomegaly

and cardiomegaly

4. Heart murmurs

5. History of pneumonia

6. Mildly pale

Approach to dyspnea

Cardiology cause Respiratory cause Metabolic cause Neurologic cause

Congestive heart failure

Cardinal signs

1. Tachycardia

2. Tachypnea

3. Cardiomegaly Pectus carinatum

4. Hepatomegaly History of dyspnea on lactation

( feeding difficulties > 20 min ) Poor weight gain failure to thrive

Investigation

Complete blood count

Hb 9.1 g/dl Hct 31.1 % MCV 58.2 fl

RDW 18.3%

Wbc 12,020 /mm3 ( N 32 % L 59 % )

Platelet 523,000 /mm3 Peripheral blood smear

Hypochromic microcytic anemia

no anisopoikilocytosis

Investigation

Blood chemistrry

BUN 11 , Cr 0.2 , Na 139 ,K 3.8, Cl 104 ,

HCO3 22

Ca 9.4, Mg 2.1, PO4 57

VBG ( on oxygen 1 LPM )

pH 7.363 pCO2 43.80 pO2 72.5 HCO3 25.1

O2sat 93.7

Investigation

CT ratio = 0.65 Increase pulmonary

vasculature

CXR Portable

EKG Left atrial enlargementLeft ventricular hypertrophy

Etiology of Heart disease

Congenital heart disease Acquired heart disease

Approach to congenital heart disease

CHD

Acyanosis Cyanosis

PBF

L/BVH RVH

PBF

BVH LVH RVH

PBF

LVH RVH

PBF

L/BVH RVH

-Large VSD-PDA-ECD

-ASD (often RBBB)-PAPVR

-AS-AR-CoA-MR

-PS-CoA-MS

-Truncus arteriosus-Common ventricle-TGA+VSD

-TGA-TAPVR-HLHS

-TGA + PS-Common ventricle c PS

-TA-PA cHypoplasia RV

-TOF-Ebstein anomaly-PVOD 2 to VSD, PDA

Approach to congenital heart disease

CHD

Acyanosis Cyanosis

PBF

L/BVH

-Large VSD-PDA-ECD

Approach to acyanotic heart disease

CHD

Acyanosis

PBF

L/CVH

PBF

L/BVH

-Large VSD-PDA-ECD

Echocardiogram

Gold standard for diagnosis Moderate perimembranous extended to

inlet VSD 8 mm , left to right shunt , no PDA no coarctation of aorta

EF 70 %

Large ventricular septal defect

Pansystolic murmur grade III at LLSB

Diastolic rumbling murmur grade II at apex

( Relative mitral stenosis )

Loud P2

Definite diagnosis

Congestive heart failure with moderate ventricular septal defect with failure to thrive

Ventricular septal defect

Type of VSD

Type I ( outlet or

subpulmonary or

subarterial type) Type II (membranous

type) Type III (inlet type) Type IV (muscular type)

I Subpulmonary

II membranous

III inlet

IV Muscular

Sign and symptoms

Size of VSD Symptom Sign

Small asymptomatic pansystolic murmur at LLSB

Moderate Dyspnea on exertion

CHF (about age 6-8th weeks), loud P2 , Pansytolic murmur at

Large dyspnea at rest LLSB and mild diastolic rumbing murmur at apex (relative MS)

Clinical course

Small defects, close spontaneously

(during the first 2 years) esp Type II and IV The vast majority of defects, close before

aged 4 years (may be in adults) Moderate or Large VSD : mostly remain

Complication

Pulmonary vascular obstruction disease or Eisenmenger syndrome

VSD c PS Recurrent pneumonia Infective endocarditis Aortic regurgitation esp Type I

Treatment

Small VSD : F/U q 1-2 yr ,

check AR q 2-3 years esp Type I

Moderate or large VSD : treat CHF ,surgery for

repairment before age

at 2 nd years

Surgery in VSD

Age <6 mo : CHF or recurrent pneumonia or FTT (HC) Age 6-24 mo : moderate or large VSD

P pulmonary a. > P lt venticle 2 times Age >24 mo : Qp : Qs > 2:1 Complication : pericarditis , aortic cusp prolapse ,

murmur of aortic regurgitation (< 10 yr)

Indication for surgery

Management

1. Support breathing and ventilation

2. Posture : semi-fowler position

3. Decrease physical activities :

rest often and sleep adequately

+/- sedation/analgesia

4. Medication : inotropic support, preload and afterload reduction

5. Diet : increase daily calories, “ no added salt diets ”

6. Correct precipitating cause

7. Surgical correction of CHD if indicated

Medication in CHF

1. Inotropic supportDigitalis • Loading dose = total digitalization dose = TDD in 24 hr

TDD/2 TDD/4 TDD/4

• Maintainance dose = TDD/4 devided in two given

at 12 hr interval

12 HR 6-8 HR 6-8HR

-Monitor : EKG & rhythm before each of the three digitalizing doses

Serum digoxin when suspected digitalis toxicity

Blood for serum electrolyte before & after administration

Medication in CHF

1. Inotropic supportA and B -adrenagic agonists IV

Dopamine 2–30 µg/kg/min Dobutamine 2–20 µg/kg/min Isoproterenol 0.01–0.5 µg/kg/min Epinephrine 0.05–1.0 µg/kg/min Norepinephrine 0.1–2.0 µg/kg/min

Medication in CHF

2. Preload-reducing agentsFurosemide (Lasix)

– IV 1-2 mg/dose prn– PO 1-4 mg/kg/day, divided qd–qid

Bumetanide (Bumex)– IV 0.01-0.1mg/kg/dose– PO 0.05-0.1 mg/kg/day, divided q 6– 8h

Chlorothiazide (Diuril) – PO 20-50 mg/kg/day, divided bid or tid

Spironolactone (Aldactone)– PO 1-3 mg/kg/day, divided bid or tidMonitor serum electrolyte in long term therapy

BW, urine input / output

3. Afterload-reducing agentsHydralazine (Apresoline)

IV or IM 0.1-0.5 mg/kg/dose (max 20mg )

PO 0.25-1 mg/kg/dose q 6-8h (max 200 mg/day)

Nitroglycerin 0.25-5 µg/kg/min

Nitroprusside (Nipride) IV 0.5-8 µg/kg/min

Captopril (Capoten) PO

Infants 0.1-0.5mg/kg/dose q8-12h (max 4 mg/kg/day)

Prematures: start at 0.01mg/kg/dose

Children 0.1-2 mg/kg/day q 8-12 h

Enalapril (Vasotec) PO

0.08-0.5mg/kg/dose q12-24h (max1mg/kg/day)

monitor : BP ( keep BP post Rx >/= BP pre Rx )

Medication in CHF

Treatment in this patient

Lasix ( 1 MKDose) 4.5 mg po q 8 hr Aldactone ( 2 MKDay ) 2 ml IV q 12 hr Lanoxin ( TDD 0.04) 0.04 ml po bid x one

day then Dobutamine IV 1 cc/hr

( 1cc/hr = 5ug/kg/day ) Captopril ( 0.1 MKDose ) 0.4 ml po q 8 hr

step to 3 MKDose

Monitoring in heart failure

Clinical

Dyspnea , tachypnea

Physical exam

Perfusion , RR , Sleeping pulse , liver size and consistency

Input / output per day and body weight

Progression in this patient

Day 2 : PRC has been given due to Hct 31 % Off lanoxin Captropril has been stepped up to 0.2 MKDay

Day 3 : Captropril has been stepped up to 0.3 MKDay Lanoxin oral has been given Lasix has been given because he looked more dyspnea and weight gain

Day 4 : Off Dobutamine Day 5 : Change lasix to oral form

After treated for 6 days less tachypnea , less dyspnea , liver is soft

Plan of management

Try medical treatment : Lasix 1 MKDose oral q 12 hrAldactone 2 mg/kg/dayCaptopril 0.3 mg/kg/doseLanoxin TDD 0.04Ferrous sulfate drops 2-3 mg/kg/day Follow up 3 months at cardiology clinic Surgery if failure to thrive or clinical does not improve

Take home message

– Cardinal sign of CHF : Tachypnea , Tachycardia Hepatomegaly , Cardiomegaly– CHD is vary in clinical presentation– VSD must be referred to treat before 2 yrs– The severity of disease does not depend on

loudness of heart murmur

Thank you for your attention

Special thanks

Dr. Kritvikrom

Dr.Niran

Dr. Jarupim