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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
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