PEDIATRICS II : GROUP VIII

HISTORY
A.D., a 6 year old girl was brought to a local hospital due to colds. She was diagnosed to have congenital heart disease
during infancy and was advised surgery. She was not started on any medication. The parents did not comply since she
seemed to be thriving well. Patient was apparently well.
PHYSICAL EXAMINATION:
Conversant, playful, comfortable, not in respiratory distress
HR= 96/min RR= 20/min BP= 90/60 Wt= 16kgs
anicterie sclerae, Pink conjunctivae, no lymphadenopathy, no tonsillopharyngeal congestion
No chest wall deformity, equal chest expansion, clear breath sounds, No wheezes/rales/ rhonchi
Adynamic precordium, no heaves/thrill, distinct heart sounds, normal rate, regular rhythm,
Normally split S2, grade 3/6 continuous murmur over the infraclavicular area, radiating to the back
Soft, flat abdomen, normoactive bowel sounds, no tenderness, no mass/organomegaly
Equal and bounding pulses, pink nailbeds, no edema, no cyanosis
GUIDE QUESTIONS:
1. What other information will you ask from the history?
Maternal history
Prenatal
o Mother's health during pregnancy (Complications? Illnesses?)
Natal
o Nature of labor
o Type of labor
Neonatal
o Condition at birth
o Specific problems (Infections? Congenital anomalies?)
Immunization
Specific dates of administration
Any untoward reactions?
Family history
Important diseases in the family; Including the ailments relevant to A.D.
2. What other findings will you evaluate on physical examination?
Carotid upstrokes and presence or absence of bruits
The point of maximal impulse and any heaves, lifts, or thrills
The first and second heart sounds, S1 and S2
Presence or absence of extra heart sounds such as S3 and S4
Presence or absence of any cardiac murmurs

PEDIATRICS II : GROUP VIII

Pulse rate

3. Do you think the patient has heart disease? What are the salient features?
Yes, the patient has a heart disease. The salient features of the case are:
6 years old female
Colds
Past Medical Illness: Congenital heart disease in infancy was advised to have surgery but didnt undergone one
Grade 3/6 continuous murmur over the infraclavicular area, radiating to the back
Equal bounding pulses
Normally split S2
4. What is your primary impression? Justify.
Primary impression: Patent Ductus Arteriosus (PDA)
Patients with PDA are usually asymptomatic, especially when it is only small. Bounding peripheral arterial pulses
present due to runoff of blood into the pulmonary artery during diastole. It has a classic continuous murmur described
as being machinery in quality, which is the hallmark for diagnosing PDA. The continuous murmur is heard in the upper
left sternal border with a grade of 1 to 5 (crescendo in systole and decrescendo into diastole). Patients usually appear
well and have normal respirations and heart rates.
5. What are your Differential Diagnoses?
FEATURES
ATRIAL SEPTAL DEFECT
Continuous murmur
heard at infraclavicular
area
Age of detection usually
at 6 years of age
Bounding pulse
Split S2
Murmur heard at the
upper left sternal
border
Grade 3/6 murmur
Acyanotic

PULMONARY VALVE
STENOSIS

PATENT DUCTUS
ARTERIOSUS

6. What laboratory exams will you request to confim your diagnosis?

1. Doppler echocardiography
High velocity jets of turbulent flow in the pulmonary artery can be reliably detected by color flow Doppler imaging; this
technique is sensitive in detecting even the small PAD. The test allows the doctor to clearly see any problems with the
heart is formed or the way it works. It is the most important test available to baby cardiologist to diagnose the heart
problem and follow the problem over time. It also used to see how well the treatments are working.
2. Electrocardiogram
An EKG is a simple, painless test that records the electrical activity. For babies who have PAD, an EKG can show whether
the heart is enlarged.
3. Pulse oximetry/ABG
Pulse oximetry / arterial blood gas analysis usually demonstrate normal saturation because of pulmonary over
circulation. A large PDA could cause hypercarbia and hypoxemia from congestive heart failure.

PEDIATRICS II : GROUP VIII

7. Initial Management:
Is pharmacologic intervention necessary? If yes, what drug/s will you give?
In A.D. management through pharmacologic intervention is no deemed necessary, as A.D. is 6 years old and there is no
recommendation for the use of Indomethacin or Ibuprophen, as it only shown to be effective in newborns.
8. What is the definitive management of this case?
Surgical Management:
In the absence of severe pulmonary vascular disease and predominant left-to-right shunting of blood, patent ductus
should be ligated or divided with surgery/catheter. (If premature infants with Respiratory distress, Pharmacologic
management required.)
Small PDAs are closed with intravascular coils.
Moderate to large PDAs closed with an umbrella like device or with a catheter introduced sac into which several coils
are released.
Cardiac Catheterization: Use of percutaneous route to close PDA. Transcatheter occlusion is an effective alternative to
surgical intervention and is becoming the treatment of choice for most PDA cases.
Surgical ligation: Treatment of choice for large PDA.
In patients with small PDA, raitionale for closure is prevention of bacterial endarteritis or other late complications.
In patients with moderate to large PDA, PDA closure to treat heart failure or prevent the development of pulmonary
vascular disease or both.
Pathophysiology Diagram