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Tetralogy of Fallot long case discussion
- 1. Department of Cardiology dr.md. Abu faisal D-card student DMCH
- 2. Name -Ms. Lamia Age -10 years Sex -Female Occupation - Student Religion - Islam Address – Potuakhali,Barisal Date of admission - 13/11/2017 through OPD Date of Examination - 14/11/2017 Cardiology DMCH
- 3. Severe Breathlessnessfor 2-3weeks Bluish discoloration of tongue,lips,fingers & toes during exertion since childhood Cardiology DMCH
- 4. According to thestatement of patient’s attendant she has been suffering from shortness of breath during exertion since her childhood. Initially it was on moderate to severe activity. But it is progressively increased, Now it occurs on mild exertion for last few weeks. She felt comfortable at rest and on lying flat and there was no H/O sudden awakening from sleep at mid night due to breathlessness. Breathlessness occurs during playing and relieved on squatting position. Breathlessness is not associated with cough, chest pain, fever, coughing out of blood, and there is no seasonal or diurnal variation, wheeze, h/o allergy or swelling of any part of the body. It does not aggravate on exposure to cold, dust, fumes or any allergens. Her mother give H/O of bluish discoloration of skin, fingers, nails, toes and lips since her childhood, which is more marked during exertion. It persistent and gradually progressive becoming more marked on exertion and not associated with change in temperature or exposure to cold. Cardiology DMCH
- 5. On queryshe mentioned fatigue during competitive activities during childhood. On repeated query her mother mentioned that the patient used to become bluish and breathlessness while feeding or crying during her childhood. But there was no h/o palpitation dizziness, sudden transient loss of consciousness, headache , blurring of vision, nausea, vomiting, bleeding from any site of the body, fever, joint pain or swelling, repeated RTI, weakness of any part of the body. But she has stunted growth. Her birth history was uneventful and her growth were delayed. Cardiology, DMCH
- 6. Not significant Pt is non diabetic and normotensive Cardiology DMCH
- 7. No suchillness runs in her family Cardiology DMCH
- 8. She belongsto a below standard socio-economic family. She lives in pucca house, drinks arsenic-free tubewell water and uses sanitary latrine. Cardiology DMCH
- 9. Her menstruationhas not started yet Immunization History She was immunized as per EPI schedule Cardiology DMCH
- 10. Appearance: Thepatient is malnourished and short statured. Co-operation: cooperative Decubitus: on choice Conjunctiva: Suffused Jaundice: absent Oedema:absent Cyanosis:Central cyanosis There is generalized clubbing(Involving all fingers & toes) Koilonychias, leukonychia, lymphadenopathy : absent Thyroid gland not palpable. Cardiology DMCH
- 11. Pulse: 104beats/min,regular in rhythm, no radio radial and radio femoral delay BP: 100/70 mm of Hg on both upper limbs Respiratory rate: 29 breaths/min Temp: 99 degree Fahrenheit JVP: Not raised Cardiology DMCH
- 12. Pulse: 104beats/min,normal volume, character, regular in rhythm No radio radial and radio femoral delay Condition of the vessel wall is normal All the peripheral pulses are normal Pericardium : Inspection: No visible apical impulse No epigastric pulsation. No scar mark or bony deformity. Cardiology DMCH
- 13. Palpation:- Apexbeat is located in left 5th intercostal space, 7cm from midsternal line, just medial to midclavicular line, normal in nature No Left parasternal heave No Thrill No palpable pulmonary component No epigastric pulsation Cardiology DMCH
- 14. First heartsound is normal in all areas Second heart sound is single There is an ejection systolic murmur in the pulmonary area(left 2nd & 3rd intercostals space) increasing intensity with breath hold in inspiration. Grading of the murmur is 3/6 There is no added sound Lung base are clear Cardiology DMCH
- 15. Reveals noabnormality. Cardiology DMCH
- 16. The ptMs. Lamia, 10-years-old, hailing from Potuakhali, Barisal got admitted into DMCH through outpatient department on 13/11/2017 with the complaints of breathlessness for 2-3 weeks ,bluish discoloration of tongue, lips, fingers and toes. According to the statement of patient’s attendant her breathlessness was less marked in early age, only felt during moderate to severe activity. But it is progressively increasing, now it occurs with mild exertion for last few weeks and she felt comfortable at rest and on lying flat and there was no h/o awakening from sleep at mid night due to breathlessness. Cardiology DMCH
- 17. Breathlessness is notassociated with cough, chest pain, fever, coughing out of blood, diurnal and seasonal variation, wheeze. On query her mother also noticed bluish discoloration skin, fingers, nails, toes and lips since childhood, which is marked more during exertion and less by taking squatting position. Her mother mentioned that the patient used to become bluish and breathlessness occurs more on feeding & crying. There was no h/o fever, joint pain or swelling, headache, palpitation and dizziness Cardiology DMCH
- 18. On general examination,the patient is ill looking and malnourished, central cyanosis(involving tongue,lips,fingers and toes),clubbing(involving all fingers and toes), Examination of cardiovascular system, there is no visible cardiac impulse, apex beat is located in left fifth intercostal space just medial to the midclavicular line, and there is no thrill and no left parasternal heave. on auscultation first heart sound is normal in all area, second heart sound is usually single. Cardiology DMCH
- 19. There is anejection systolic murmur in the pulmonary area(left 2nd & 3rd intercostal space) increasing intensity with breath hold in inspiration. Grade 3/6,there is no added sound, Lung base are clear. Cardiology DMCH
- 20. Congenital cyanotic heartdisease, most likely Tetralogy of fallot Cardiology DMCH
- 21. 1. DORV withSevere Pulmonary Stenosis 2. VSD and PS Cardiology DMCH
- 22. CBC: Hb :18.9 gm/dl TWBC : 7000/cumm Neu : 47 % Lym : 42% ESR : 10 mm in 1st hour HCT : 66% Cardiology DMCH
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- 28. Medical management Interventional management Surgical management Cardiology DMCH
- 29. Immediate positionalchange(knee-chest position or squatting position) High flow oxygen inhalation Sedation-preferably Injection Morphine sulphate(0.1 mg/kg) Sodium bicarbonate-to combat acidosis Volume expansion with IV fluid Beta blocker(Propranolol) –oral route or in emergency IV(0.5 to 1.5 mg/kg every 6 hourly) Cardiology DMCH
- 30. Palliative surgery: Childrencan undergo surgery at an early age. Most common operation was the Blalock- Taussing shunt(subvlavian artery to pulmonary artery graft anastomosis) Waterston shunt(left PA to ascending aorta) Pot’s anastomosis(left PA to descending aorta. Cardiology DMCH
- 31. Complete correctiveprocedures in Tetralogy of Fallot involve VSD closure, incorporating the aorta into the LV and relieving RV outflow tract obstruction. This usually involves resecting the hypertrophied infundibular myocardium, with patch enlargement of the outflow tract. Cardiology DMCH
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