Tof long case

TOF long case DR Faisal Dcard Student, Dhaka Medical College Hospital,Dhaka

1. Department of Cardiology
dr. md. Abu faisal
D-card student
DMCH

2. Name -Ms.Lamia
Age -10years
Sex -Female
Occupation -Student
Religion -Islam
Address –Potuakhali,Barisal
Dateofadmission -13/11/2017throughOPD
DateofExamination-14/11/2017
Cardiology DMCH

3. Severe Breathlessness for 2-3weeks
Bluish discoloration of tongue,lips,fingers & toes
during exertion since childhood
Cardiology DMCH

4. Accordingtothestatementofpatient’sattendantshehasbeen
sufferingfromshortnessofbreathduringexertionsinceher
childhood.Initiallyitwasonmoderatetosevereactivity.Butit
isprogressivelyincreased,Nowitoccursonmildexertionfor
lastfewweeks.Shefeltcomfortableatrestandonlyingflatand
therewasnoH/Osuddenawakeningfromsleepatmidnight
duetobreathlessness.Breathlessnessoccursduringplaying
andrelievedonsquattingposition.
Breathlessnessisnotassociatedwithcough,chestpain,fever,
coughingoutofblood,andthereisnoseasonalordiurnal
variation,wheeze,h/oallergyorswellingofanypartofthe
body.Itdoesnotaggravateonexposuretocold,dust,fumes
oranyallergens.
HermothergiveH/Oofbluishdiscolorationofskin,fingers,
nails,toesandlipssinceherchildhood,whichismoremarked
duringexertion.Itpersistentandgraduallyprogressive
becomingmoremarkedonexertionandnotassociatedwith
changeintemperatureorexposuretocold.
CardiologyDMCH

5. On query she 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 such illness runs in her family
Cardiology DMCH

8. She belongs to a below standard socio-economic
family.
She lives in pucca house, drinks arsenic-free
tubewell water and uses sanitary latrine.
Cardiology DMCH

9. Her menstruation has not started yet
 Immunization History
She was immunized as per EPI schedule
Cardiology DMCH

10. Appearance: The patient 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:-
Apex beat is located in left 5
th
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 heart sound is normal in all areas
Second heart sound is single
There is an ejection systolic murmur in the
pulmonary area(left 2
nd
& 3
rd
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 no abnormality.
Cardiology DMCH

16. The pt Ms. 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 not associated 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 an ejection systolic murmur in the
pulmonary area(left 2
nd
& 3
rd
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 heart disease, most likely
Tetralogy of fallot
Cardiology DMCH

21. 1.DORV with Severe 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 1
st
hour
HCT : 66%
Cardiology DMCH

23. Cardiology DMCH

24. Cardiology DMCH

25. Cardiology DMCH

26. Cardiac catheterization
Cardiology DMCH

27. Tetralogy of Fallot
Cardiology DMCH

28. Medical management
Interventional management
Surgical management
Cardiology DMCH

29. Immediate positional change(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:
Children can 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 corrective procedures 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

32. Cardiology DMCH