PAEDIATRICS CVS CASE

By Dipasha Agarwal, Final Year MBBS,

HBTMC and Dr. RN Cooper Hospital, Mumbai
 Demographic Details

Aashna Kaur, a 12 year old female child residing

at Andheri, hailing from Punjab
Informant- Mother(reliable)
came to the paediatric opd with chief
complaints of :

Recurrent respiratory tract infections since the age

of 3 years
Palpitations since 1 year
 History of Presenting Illness
The patient was apparently alright before 3 years of
age, after which she started to experience recurrent
episodes of lower and upper respiratory tract
infections which are gradual in onset, previously they
occurred once or twice in 4 months and now have
progressed to once in every 6weeks. It lasts for 3-5
days and is associated with sore throat, cough with
minimal expectoration with no diurnal variation.
Episodes of lower resp tract infections were more
compared to upper resp tract. 
There are no identified aggravating factors
and it relieves on medications. No
hospitalisation is required during any
episode.
There is no history of fever, ear discharge,
joint pains, skin rash, headache, dizziness.
She also complained of palpitations since 1 year
which are sudden in onset, non progressive, occurs
intermittently once or twice in 3 months, lasts for
around 1 minute, not associated with breathlessness
and sweating. There are no identified aggravating
factors, it relieves spontaneously. There is no
history of post palpitations- diuresis.

Further questioning also revealed poor weight gain

since age of 8 years, easy fatigability( which has
progressed from NYHA class 1 to 2)
and dyspnea present on exertion.
 Negative History
There is no history of  PND, orthopnoea,
cyanosis, syncope, chest pain, haemoptysis,
swelling over body or convulsions. 
No history of any bleeding tendencies, loss of
appetite, ingestions of worms, pica
 Past History
No past history of Tb/Tb contact, asthma,
epilepsy or any illness requiring hospital
admission.
 Antenatal History
The child was born out of a 3rd degree consanguineous
marriage, it was a spontaneous conception
The mother registered herself in first trimester and
followed up with regular ANC visits and USG scans( 1 st
visit, 5th month, 9th month)
Regular intake of iron, calcium and folic acid was done.
No history of fever with rash or any other illness,
exposure to radiation and consumption of drugs.
No history of hypertension, gestational diabetes,
anaemia, jaundice, lymphadenopathy, blood transfusion
and IUGR.
 Natal History
Delivered at a government hospital
It was a normal vaginal delivery at full term
Baby cried immediately
Birth weight- 3 kg
SpO2 at birth- 98%
No NICU admission required
No other complications
 Postnatal History
Birth order- 1
Initiated breast feeding soon after birth,
exclusively done till 6 months and thereafter
continued up to 2 years of age.
No pre lacteal feeds were used.
Passed meconium and urine within 24 hours
 Nutrition History
 Diet- Vegetarian.

 According to 24 hr recall method,

Morning Milk 200ml Calorie(kcal) Protein(g)
& Evening 120 6

Biscuits(4) 80 0.8
Afternoon Rice 1 cup 200 4

Sambhar 1 cup 130 7

Night 2 chapati 160 5

Dal 1 cup 80 6
Vegetable ½ cup 25 2

Total: 995 kcal/d 37.6

Required: 2000kcal/d 40g/d
Deficient: 1005kcal/d 2.4g/d
 Personal History

Menarche- Not attained

Sleep- Sound and adequate
Allergies- None
Addictions- None
Bowel and bladder- Regular
Medications- No history of any chronic
medications
 Developmental and Immunisation
History

According to mother all milestones are achieved

without any delay and she is currently studying in
7th std at school with good scholastic performance.

Immunisation is up to date.
 Family History
Sibling- 1, 5year old younger brother- healthy

42 yr 45 yr

5 yr 12 yr

No history of similar illness in family.

No history of congenital anomalies in family
members.
 Socioeconomic History
Head of family- Mother
No. of family members- 4
No. of earning members-2
Per capita income-Rs. 15,500
Kuppuswamy Class III( lower middle class)
Lives in pucca house, drinks boiled water and
uses sanitary latrine.
 Summary
Based on history,
Differential diagnosis are
a. Congenital Heart Disease which is
acyanotic
b. Anemia
c. Immunodeficiency disorder
 General Examination
Patient was examined with due consent in a well lit room.
She was conscious, coherent and well oriented to time
place and person. She is poorly built and malnourished
( gracile habitus)

Vitals:
1. Pulse-105 beats/min, regular in rhythm, no radio-radial
and radio-femoral delay. Peripheral pulses felt. JVP not
raised
2. Afebrile on touch
3. RR-25/min
4. BP-100/70 mm of Hg in right upper limb on supine
position and dropped by 6mm Hg on standing.
Height-143 cm( Expected- 148cm +/-
14cm(2SD))
Weight- 26 kg ( Expected- 39 +/- 18(2SD) kg)
BMI = 12.7 kg/m2 (Expected- 18 +/- 6(2SD))

No pallor, icterus, cyanosis, clubbing, pedal

edema or lymphadenopthy detected.
HEAD TO TOE EXAMINATION:

1. Hair-Normal
2. Head- Normal
3. Face- No dysmorphism
4. Oral cavity- Multiple dental caries and enlarged
tonsils, no congestion
5. Neck- No webbed neck, swelling or pulsations.
6. Hands- No skeletal abnormality
7. Nails- No koilonychia, cyanosis, clubbing
8. Skin- No rash or any neurocutaneous marker
 Systemic Examination
CVS EXAMINATION
1. Inspection:
a) Shape of chest- Normal
b) Trachea- Appears central
c) Apex beat- Seen at the 5th intercostal space 1cm
medial to mid clavicular line
d) Precordial movement seen at left parasternal
border
e) No scars or dilated veins are visible
f) No epigastric pulsations seen
2. Palpation:
a) Inspectory findings are confirmed on palpation
b) Apex beat- Felt at the 5th intercostal space 1cm
medial to mid clavicular line which is poorly
localised over 3cm
c) Left parasternal heave is present
d) Palpable P2 in pulmonary area
e) No thrill present
3. Auscultation:
( patient is in sitting position and heard with
diaphragm of the stethoscope)

a) S1 is accentuated and heard in all areas, more

prominent in tricuspid area.
b) Wide, fixed splitting  loud S2 heard in
pulmonary area
c) There is an ejection systolic murmur in the left
2nd and 3rd intercostal space with no radiation and
grading of murmur is 2/6
d) There is also mid diastolic murmur heard in
tricuspid area
RESPIRATORY SYSTEM
a) Air entry bilaterally equal
b) Vesicular sounds heard over chest
c) No added sounds
d) Trachea central
e) No intercostal retractions or use of accessory
muscles of respiration

PER ABDOMEN
a) No hepato-splenomegaly
b) No dullness on percussion
 Provisional Diagnosis

Congenital Heart Disease, most likely Atrial

Septal defect, which is large in size, likely
to be associated with mild pulmonary
hypertension and without any signs
suggestive of ventricular dysfunction or
congestive cardiac failure.
 Differential Diagnosis
Pulmonary stenosis
Ventricular septal defect
Partial anomalous pulmonary venous connection
Pulmonary hypertension
Anaemia
Ebstein anomaly
Mitral regurgitation
Idiopathic dilation of pulmonary artery
Aortic stenosis
Immunodeficiency disorder
 Management
Investigations:
1. General:
Complete blood count, ESR
Peripheral smear
2. Specific:
Chest X-Ray
ECG
2D Echo

Treatment: 
a. Conservative therapy- Diuretics and symptomatic treatment of
infections with antibiotics.
b. Definitive surgery- Device closure.
THANK YOU