Presenting Complains:
- Breathlessness for … months
- Bluish discoloration of the lips and fingers during exertion for … months
- Weakness for … months
- Palpitation for … months
- Chest pain for … months
- Cough for … months.
History of Presenting Complains: According to the patient’s statement, she has been suffering from
breathlessness since her childhood. Her breathlessness was less marked in earlier stage, only felt
during moderate to severe activity. But for the last few months, it is progressively increasing, even
during mild exertion. There is no seasonal variation of breathlessness and it is not associated with
exposure to dust, pollen or fume. There is no history suggestive of paroxysmal nocturnal dyspnea or
orthopnea. The patient also noticed bluish discoloration of skin, finger nail, toes and lips for the last
… months, which is more marked during exercise and less by taking squatting position. She also
experiences diffuse chest pain, usually following any activity or after eating, which radiates to left
shoulder and subsides after taking rest. She also complains of palpitation, weakness and occasional
dry cough. Her bowel and bladder habits are normal. Her mother mentioned that the patient used to
become bluish and breathless while feeding or crying during the first few years of life.
On General Physical Examination:
- The patient is emaciated and short in stature
- Dyspneic
- Central cyanosis (involving tongue, lips, fingers and toes) is present
- There is generalized clubbing (involving all fingers and toes)
- Pulse: 112/min, low volume, regular in rhythm and normal character
- BP: 100/60 mm Hg
- Temperature: 98ºF
- Respiratory rate: 28/min
- No anemia, leukonychia, koilonychia, edema, jaundice, lymphadenopathy or thyromegaly
Cardiovascular system
- Pulse: 112/min, low volume, regular in rhythm and normal character
- BP: 100/60 mm Hg
- JVP: prominent “a” wave
- Visible cardiac impulse in apical and epigastric region
- Apex beat—palpable in the left … intercostal space, … cm from midline, normal in character
- Left parasternal lift and epigastric pulsation—present
- Systolic thrill—present in pulmonary area.
- First heart sound—normal in all the areas
- Second heart sound—P2 is soft (or absent) in pulmonary area, A2 is normal
- There is a harsh ejection systolic murmur in the pulmonary area, which radiates to the neck, more
on inspiration.
Examination of other systems reveals normal findings.
What is the Provisional Diagnosis?
Tetralogy Of Fallot (TOF)
Mention some cyanotic congenital heart disease.
As follows:
- Tricuspid atresia
- Transposition of great vessels
- Pulmonary atresia
- Ebstein’s anomaly.
What investigations are done in TOF?
As follows:
- Chest x-ray- shows boot-shaped heart, pulmonary conus is concave (small pulmonary artery), right ventricle enlarged (prominent elevated apex), oligemic lung, right-sided aortic arch in 25% cases.
- 2D echocardiography and color Doppler (diagnostic—it shows that the aorta is not continuous with the anterior ventricular septum).
- Other investigations: ECG (RVH), cardiac catheterization in some cases.
