Welcome to Clinical Meeting

Dr. KANTA HALDER Resident (MD;Phase A),

General Pediatrics;BICH.

Particulars of the patient Name: Abdur Rahman. Age: 11 months. Sex: Male. Address: Charparamukhi, Chandpur. Date of Admission: 09.06.2016. Date of Examination: 16.06.2016.

Chief Complaints

Cough for 7 days. Respiratory distress for same duration. Not growing well since early infancy.

History of present illness According to the statement of mother, her

child has developed non productive cough and respiratory distress for 7 days which aggravates during feeding and lying position. He had H/O same type of illness twice since his 4 months of age and treated accordingly. Mother also complained that her child is not growing well in comparison to other peers since early infancy.

Cont.. With these complaints they consulted a local

peditrician who advised some oral medication and then referred the child to Dhaka Shishu Hospital for further evaluation & better management.

History of Past illness He had H/O same type of illness twice

during his 4 month and 7 month of age. His last episode required hospitalization for 7 days and diagnosed as a case of congenital heart disease.

Treatment History During his previous hospitalization he was

treated accordingly and discharged after improvement with some oral medications.

This time he is getting some injectable and oral medication, but mother could not mention the names.

Birth History Antenatal : Mother, 21 years old lady, was on

irregular antenatal check up and was normotensive & nondiabetic. She had no history of fever with rash or taking any offending drug during her pregnancy period.

Natal : He was delivered normally at term at home with average birth weight.

Postnatal : Baby cried immediately after birth.

Feeding History He was on exclusive breast feeding up to 4

months of age. Then complementary feeding was started with suji prepared with cow’s milk which was given 3 times daily along with breast feeding. Khichuri was started from 7 months of age with adequate protein & calorie. Now he is on family diet. Mother told that her child had difficulty in feeding. Calorie deficit.

Developmental History He is developmentally age appropriate.

Immunization History He is immunized as per EPI schedule.

Family History He is the only issue of his non-

consanguineous parents. His other family members are healthy.

Socio-economic History He belongs to a low socio-economic family.

General Examination Appearance: Dyspnoeic, irritable and

emaciated. Anaemia: Mild. Jaundice: Cyanosis: Clubbing: Absent Dehydration: Ankle oedema: Absent.

Cont..Neck Vein: Not engorgedSkin: BCG mark present.Lymphnode: Not palpable.Ear:Nose: NormalThroat:Signs of meningeal irritation: Absent.

Cont..Vital Signs:

Pulse: 140/min.Respiratory Rate: 52/min.Temperature: 98°F.Blood Pressure: 70/20 mmHg.

Anthropometry:

Cont..

Weight: 6 kg.Height: 69 cm.HAZ: -2.25 (moderately stunted).WHZ: -4.4 (severely wasted).

Systemic Examination

Respiratory system : Inspection : Respiratory rate: 52/min.

Shape of the chest is normal & movement is bilaterally symmetrical. Subcostal indrawing is present.

Palpation : Trachea is centrally placed. Apex beat is in left 6th ICS, lateral to mid-

clavicular line. Chest expansion : Normal.

Vocal fremitus is normal in mid clavicular, mid axillary & post. scapular line.

Cont..

Percussion: Percussion note is resonant in MCL, MAL &

PSL in both lung field.Auscultation: Breath sound is vesicular and vocal

resonance is normal in MCL, MAL & PSL in both lungs.

No added sound.

Cont..

Cont.. Cardiovascular System: Pulse: 140/min, regular, bounding in nature,

No brachio-femoral delay. Blood pressure: 70/20 mmHg. Precordium:

Inspection:Shape of chest: Normal.Hyperdynamic precordium..Engorged vein: Absent.

Palpation: Apex beat: Left 6th ICS, lateral to mid-

clavicular line, thursting in nature.Thrill: Absent.P2: Not palpable.Lt. parasternal heave: Absent.

Cont..

Auscultation:1st & 2nd heart sounds are audible in all 4

areas.There is a continuous machinery murmur,

best heard at left upper sternal border, grade 3/6 without any radiation.

Basal crepitation: Absent.

Cont..

Cont..

Abdominal Examination: Inspection:

Abdomen is mildly distended.Flanks are not full.

Umbilicus is centrally placed & inverted.

Cont.. Palpation : Abdomen is soft, non tender.

Liver is palpable 3.5 cm from right costal margin along the mid clavicular line which is non tender, surface is smooth, regular border. Upper border of liver dullnes present at right 5th intercoastal space. Spleen: Not palpable.

Kidneys: Not ballotable. Fluid thrill: Absent.

Cont.. Percussion: Shifting dullness: Absent. Auscultation:

Bowel sound: Present. Genitalia: Normal.

Other Systemic examination: No abnormality.

Salient features Abdur Rahman, 11 months old boy has

presented with cough and respiratory distress for 7 days and not growing well since early infancy. He has H/O same type of illness previously. He is dyspnoeic, irritable, mildly pale and emaciated. He is moderately stunted and severely wasted. He has tachypnoea, bounding pulse with wide pulse pressure.

Salient features (cont..) There is cardiomegaly and a continuous

machinery murmur, best heard at left upper sternal border, grade 3/6 without any radiation. There is hepatomegaly without ascites. Other systems reveal normal findings.

Provisional Diagnosis

Congenital acyanotic heart disease (Patent Ductus Arteriosus) with Heart Failure with secondary malnutrition.

Differential Diagnosis

AP Window with Heart Failure with secondary malnutrition.

InvestigationsComplete Blood Count :

• Hb: 9.4 gm/dl.• WBC: Total count: 11,800/mm3. Differential count:

o Neutrophil: 60%o Lymphocyte: 36%o Monocyte: 03%o Eosinophil: 01%o Basophil: 00%

Cont..

o RBC: Anisocytic anisochromic.o WBC: Mature with above

distribution.o Platelet: Adequate.

• Platelet: 417,000/mm3.• PBF:

ECG

Cont.. Color Doppler Echocardiography: • Large PDA shunting Lt to Rt.• MPV with severe MR.• Hugely dilated LA & LV.• Moderate Pulmonary Hypertension.• Good bi-ventricular function.

Cont..

S. Creatinine: 33.2 µmol/L. S. Electrolytes:

Na+: 132.0 mmol/L.K+: 4.0 mmol/L.

Cl-: 92.2 mmol/L. CRP: 10.4 mg/L.

Final Diagnosis

Large Patent Ductus Arteriosus with moderate pulmonary hypertension with Heart Failure with secondary malnutrition.

Management Counseling to the parents. General supportive & symptomatic

management: • Bed rest.• Propped up position.• O2 inhalation. • Fluid restriction (100 ml/kg).

Management (cont..)• Nutritional support: NG tube feeding: F-75 (50 ml 3 hourly) along

with breast feeding. Multivitamin & mineral supplementation.• Management of heart failure: Digitalization. Inj. Frusemide 6 mg 12 hourly. Tab. Enalapril 0.5 mg 12 hourly. Syp. Digoxin 0.5 ml 12 hourly.

Management (cont..)• Antibiotics: Inj. Ceftriaxone 500 mg once daily. Inj. Flucloxacillin 125 mg 6 hourly.

Specific Treatment: PDA device closure.

Thank You