Morning Report

January 13, 2012 David Levy

HPI: 15 month girl with noisy breathing and cough. Started at about 3-4 months of age. Pt hospitalized at this time for respiratory distress but discharged next day. Noisy breathing present daily and family has not noticed any particular exacerbating factors. PCP thought possibly RAD and has started albuterol, pulmicort, and singulair but not much improvement with any medicines. Has received antibiotics 3 times for possible pneumonia and symptoms improved somewhat but never resolved. PMH: Prior hospitalization for respiratory distress, no home O2. No surgeries. Otitis media twice. Term NSVD, no complications. BW 3430g (20%) ROS: No frequent fevers or infections. Family feels like gaining weight appropriately. No diarrhea, no constipation, no steatorrhea. Otherwise negative. Development: Normal for gross motor, fine motor, speech/language, social SH: Lives with parents and older sister in Provo. No smoke exposure. Family has two cats as pets. FH: Asthma (mom, MGM). Negative for heart disease, CF, pulmonary disease. Meds: Albuterol, Pulmicort, Singulair Allergies: None

PE:
VS: T 97.3, HR 121 (crying), RR 22, BP 96/58, SO2 96% on RA Wt 8.38kg (3%), Ht 73.5cm (15%) General: Alert, happy, HEENT: NC/AT. PERRL. Conjunctivae clear., sclera anicteric. PERRL. Ear canals clear, TMs gray with normal landmarks. Nares patent with normal mucosa, septum, and turbinates without polyps. MMM. Tonsils non-erythematous, no exudates. No palatal petecchiae. Neck: Supple, no thyromegaly. Resp: Normal work of breathing with good air entry. Symmetric configuration. Good air entry bilaterally. Coarse inspiratory and expiratory rhonchi heard in all lung fields. CV: Regular rate and rhythm without murmur. Pedal pulses 2+. Cap refill 2+. Abd: Soft, flat and nontender without hepatosplenomegaly or other masses. Bowel sounds positive. Lymphatic: No adenopathy. MSK: Normal strength and tone without atrophy. Extremities: No clubbing, cyanosis or edema. No swelling. Skin: No rashes or other lesions. Neurological: CN 2-12 grossly intact. Tone grossly normal. No apparent focal deficit.

Vascular Rings

Double aortic arch

Right sided aortic arch

Pulmonary sling

Associated anomalies

Cardiac (most common)

VSD PDA Tetralogy of Fallot Aortic coarctation Cleft lip/palate Tracheoesophageal fistula Subglottic stenosis Genetic syndromes: (DiGeorge, Down, CHARGE)

Other

Diagnosis

CXR CT MRI/MRA Echo

To assess for other intracardiac lesions

Treatment

Surgery

References

Turner A, Gavel G, Coutts J. Vascular ringspresentation, investigation and outcome. Eur Journal Pediatrics 2005. 164: 266-. Bakker DA, Berger RM, Witsenburg M, Bogers AJ. Vascular rings: a rare cause of common respiratory symptoms. Acta Paediatr 1999. 88:947. Uchida D. Late Presentation of Double Aortic Arch in School-Age Children Presumed to Have Asthma: The Benefits of Spirometry and Examination of the Flow-Volume Curve. Respiratory Care 2009. 54: 1402-1404.

Pictures from: http://www.childrenshospital.org/cfapps/mml/index.cfm?CAT=media&MEDIA_ID=2018 http://www.childrenshospital.org/cfapps/mml/index.cfm?CAT=media&MEDIA_ID=2019 http://www.nlm.nih.gov/medlineplus/ency/imagepages/19880.htm