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

2. C.F. 2 months old / male CC: Fever Gestational 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 History Full term 3.2 kg (N 3-3.5 kg) via NSD, singleton, cephalic presentation at a local hospital No complications APGAR not known

3. C.F. 2 months old / male CC: Fever Feeding History Mixed breastfeeding and milk formula No feeding difficulty (-) cyanosis Developmental History No regular check-up At par with development

4. C.F. 2 months old / male CC: 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 hours PTA Symptoms persisted ADMISSION

5. 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

6. 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

7. Family Profile

8. Family History (+) Rheumatic Heart Disease – maternal grandmother (-) HPN (-) Diabetes Mellitus (-) Pulmonary Tuberculosis (-) Allergies

9. 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

10. 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

11. 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

12. 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

13. 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

14. Subjective Salient Features

15. Objective Salient Features

16. Clinical Impression Congenital Heart Disease Pneumonia

17. Differential diagnosis CHDCyanotic Non- cyanotic

18. VSDASDPDA AS PS CoA Shortness of breath Fast breathing Hard breathing Paleness Failure to gain weight Fast heart rate Sweating while feeding Frequent respiratory infections Difficulty breathing (dyspnea) Frequent respiratory infections in children Sensation of feeling the heart beat (palpitations) in adults Shortness of breath with activity Bounding pulse Fast breathing Poor feeding habits Shortness of breath Sweating while feeding Tiring very easily Poor growth Breathlessness with activity Chest pain Fainting, weakness, or dizziness with activity Palpitations Abdominal distention Cyanosis in some patients Chest pain Fainting Fatigue Poor weight gain or failure to thrive in infants with severe blockage Shortness of breath Sudden death Dizziness or fainting Shortness of breath Pounding headache Chest pain Cold feet or legs Failure to thrive Poor growth

19. VENTRICULAR SEPTAL DEFECT

20. Ventricular Septal Defect most common ACHD (25%) SYNONYMS * Roger’s disease * Interventricular septal defect * Congenital cardiac anomaly

21. 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 cm 2 ) - right ventricular pressure is normal Large nonrestrictive VSDs (usually >1.0 cm 2 )- right and left ventricular pressure is equalized

22. Anatomical Classification Membranous/ perimembranousVSD –Most common CHD (males>females) Muscular VSD –“Swiss cheese” VSD Supracristal VSD –Least common

23. The contribution of pulse oximetry to the early detection of congenital heart disease in newborns Romaine Arlettaz, Andrea Seraina Bauschatz, Marion Mönkhoff, Bettina Essers, Urs Bauersfeld Eur J Pediatr (2006) 165: 94–98

24. 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

25. Methods Study design: prospective multi-centre study Zurich, Switzerland; May 2003 to May 2004 Population: infants above 35 weeks of gestation (n=3,262)

26. Methods

27. Results

29. 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