CARDIOLOGY

Signature over printed name of Examiner: ________________________________________________

Examiner reads the trigger problem to the examinee.

Pida, 6-month old, female, came to your clinic because of poor weight gain.

P RESIDENTS
1. WHAT PERTINENT INFORMATION FROM THE
O
HISTORY WOULD YOU LIKE TO KNOW?
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S

A. Nutritional History 1
- Type of feeding? (exclusively breastfed, formula, 1
whole milk, etc)
- If formula fed, dilution of the milk? 1
- Other liquids given to the baby? (Water, tea, 1
juices, etc)
- Have solids (Complimentary feeding) been 1
introduced already?
B. Are there any medications being given? 1
C. Is there vomiting during or after feeding? 1
D. Is there recurrent diarrhea? 1
E. Is there a history of recurrent infections, like 1
respiratory tract infections, otitis media, UTI, etc.
F. Is there a history of interrupted feedings? Sweating 1
during feeding? Cyanosis?
G. Is there a history of snoring or apnea? 1
H. Have there been adequate well-baby visits? 1
I. Are immunizations up to date? 1
J. Birth and maternal history 1
- Was there any maternal infection? 1
- Was the baby born term? Preterm? 1
- What was the birth weight? 1
- Was there a history of maternal 1
K. Family History – inadequate growth or short stature, 1
genetic syndromes
Other pertinent data not included in the list (1 point each
but the total score should not exceed 19 points).
TOTAL SCORE 19
SHOW THE HISTORY.
History of the Present Illness:
Born to a 40-year-old G3P3 (2103), non-smoker, non-alcoholic beverage drinker, with irregular pre-natal check-up done at a
local health center with a midwife. Ultrasound was not done. On the 3 rd month AOG, the mother had foul smelling vaginal
discharge, self-medicated with unrecalled antibiotics for 2 days. No known exposure to viral exanthems or radiation.

On the 35th week of gestation, the mother noted vaginal spotting followed by regular abdominal contractions. The mother was
subsequently brought to a lying-in clinic, where the patient was delivered preterm, no cord coil, no meconium stained amniotic
fluid, with good cry and activity. New born care was rendered, Hepa B and Vitamin K were given. Birth weight was 2.1kg.
APGAR was not done. There was no cyanosis or jaundice noted.
In the interim, the patient was purely breastfed; however, the mother would note sweating while feeding. No cyanosis was
noted, no snoring, no apneic episodes, no consult was done. No medications were given.

On the 3rd month of life, mother noted that her baby was smaller than other babies of her age. The baby was also noted to
have cough and fast breathing, with undocumented fever. There was no vomiting, no loose stools. The patient was brought to
the local health center and was given Amoxicillin at 40MKD. The mother was advised that a cardio consult should be done,
however this was not facilitated.

On the 6th month of life, due to persistence of poor weight gain, the patient was brought to the OPD for consult.

Family History:
No history of short stature, genetic syndromes, or cardiac disease.

P RESIDENTS
2. WHAT WILL YOU LOOK FOR IN THE PE?
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A. General survey: Is the patient awake, alert, in 1
cardiorespiratory distress?
B. Vital signs: BP (Check for wide pulse pressure), 1
cardiac rate, RR, temperature
C. Anthropometrics: Weight, Length, Weight for length, 1
head circumference
D. Nose: Alar flaring 1
E. Mouth: Check for cyanosis of lips or tongue 1
F. Neck: CLADS, neck vein distention 1
G. Chest & Lungs: Check for retractions, crackles, 1
wheezes
H. Cardiac findings 1
- Dynamic precordium, precordial heave 1
- Check for cardiomegaly by palpating for the point 1
of maximal impulse
- Check for thrills 1
- Check for murmurs: Timing, location, radiation, 3
intensity
- Auscultate for S1, and S2, and look for S3 and S4 1
if present
I. Abdomen: Abdominal distention, Hepatomegally or 1
other organomegally
J. Extremities: Edema 1
K. Pulses: Check for bounding pulses 1
L. Skin, hair – Check for dryness of skin, dermatosis, 1
hair distribution
Other pertinent data not included in the list (1 point each
but the total score should not exceed 19 points).
TOTAL SCORE 19
SHOW THE PE FINDINGS.

 Awake, not in distress

 Wt: 5.2 kg (z < -3) Length: 55cm (z < -3) WFL: no wasting Head Circumference: 41cm (z<0)
 BP: 90/50, HR 115, RR 35, Temp 37oC
 Pink palpebral conjunctiva, anicteric sclerae
 No alar flaring
 No cervical lyphadenopathy
 Moist lips, no cyanosis of tongue
 Symmetrical chest expansion, with subcostal retractions, clear breath sounds
 Dynamic precordium, apex beat 5th LICS, MCL, no heaves, thrill at 2nd left ICS, radiating to the left sternal border.
Continuous murmur, machinery-like, 4/6, best heard at the 2 nd left ICS, radiating down to the left sternal border
 Abdomen flat, normoactive bowel sounds, soft, no hepatomegally
 Bounding pulses, warm extremities, CRT <2 sec, no edema, no clubbing, no cyanosis.

4. Give at least 3 differential diagnosis for acyanotic

congenital heart diseases. Differentiate one from the
other in terms of the characteristic murmurs.
A. Patent Ductus Arteriosus 2
- Presence of the continuous machinery-like
murmur
B. Ventricular Septal Defect 2
- Presence of loud, harsh, or blowing holosystolic
murmur
C. Atrial Septal Defect 2
- However more commonly presents as fixed split
S2
Other pertinent differentials not included in the list (1
point each but the total score should not exceed 6
points).
TOTAL SCORE 6

5. (To ask the resident)

WHAT LABORATORY EXAMINATIONS SHOULD BE
REQUESTED? GIVE AT LEAST 3 AND STATE THE
RATIONALE FOR EACH.
A. Chest X-ray: 2
- Look for cardiomegally 1
- Look for increased pulmonary vascular markings 1
- Look for a prominent pulmonary artery 1
B. 2D Echocardiogram: 2
- Look for the location of the defect 1
- Look for the size of the defect 1
- Look at the flow across the defect, if it is a right to 1
left or a left to right shunt
C. Complete Blood Count 2
- Look for signs of infection, anemia. 1
Other pertinent labs not included in the list (1 point each
but the total score should not exceed 10 points).

TOTAL SCORE 13
SHOW THE LABORATORY RESULTS:

CBC: Hgb 132 g/L Hct: 41 WBC: 12.5 x10^9g/dL Seg 0.72 Lym 0.23 Mono 0.04 Eos 0.01
Chest X-ray: Cardiomegally with increased pulmonary vascular markings, pulmonary artery prominent
2dEcho: Moderate sized patent ductus arteriosus

6. WHAT IS YOUR PRIMARY IMPRESSION?

3
Congenital Heart Disease
Patent ductus arteriosus
Severe stunting
No wasting
TOTAL 3

7. WHAT IS THE PATHOPHYSIOLOGY OF PDA?

A. Failure of normal physiologic closure of the fetal 3
ductus
B. Persistent communication between the aorta and the 3
pulmonary artery
C. Produces a left-to-right shunt from the systemic 3
circulation into the pulmonary circulation
TOTAL SCORE 9

8. CAN THE PATENT DUCTUS ARTERIOSUS EXPLAIN

THE POOR WEIGHT GAIN? WHY OR WHY NOT?
- Yes, these children tire easily during their feeding 3
leading to inadequate caloric intake. The
increased work of the heart also causes
increased metabolic state and leads to poor
growth.
TOTAL SCORE 3

9. OUTLINE A PLAN OF MANAGEMENT.

(Must ask the resident the Rationale for giving the
Medication/ for the Management)
A. Surgical/Catheter closure 2
- Small PDA: For prevention of bacterial 1
endarteritis
- Moderate to large PDA: Treat heart failure or 1
prevent the development of pulmonary vascular
disease
2. Amelioration of CHF symptoms 2
- Diuretic (Furosemide) 1
- Digoxin 1
- Afterload-reducing agents (Captopril, Enalapril, 1
Nitroglycerin)
3. Antibiotics 2

- For treatment of possible concurrent pneumonia 1

Other pertinent treatment modalities not included in the list
(1 point each but the total score should not exceed 12
points).
TOTAL SCORE 12

P RESIDENTS
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10. If left untreated, give 3 possible complications that may
result from this patient’s PDA.
A. Heart failure 2
B. Infective endarteritis 2
C. Pulmonary or systemic emboli 2
D. Pulmonary hypertension (Eisenmenger syndrome) 2
E. Aneurysmal dilation of the pulmonary artery 2
Other pertinent complications not included in the list (1 point
each but the total score should not exceed 6 points).
TOTAL SCORE 6

11. COMMUNICATION SKILLS & MENTAL ALERTNESS 10

TOTAL SCORE 100