Case Presen

tation
 Patient Profile
0 BJ
0 9 years old/Male
0 Filipino
0 Single
0 Roman Catholic
0 Lapu-Lapu City, Cebu
0 Admitted for the 2nd time at PSH
 Chief Complaint
0 persistent heart murmur
 Past Medical History
0 Non-diabetic
0 Non- hypertensive
0 (+) BA -9 years,
0 Mngt: Salbutamol neb, PRN
0 Last attack: 2 mo ago
0 Previous hospitalizaton
- 2006, CHH, AGE
- 2009, PSH, BA
- 2011, SouthGen, Pneumonia
0 No history of surgical operation
 Social History
0 Non-smoker
0 Non-alcoholic drinker
0 No known food and drug allergies
 Family History
0 Heredofamilial Diseases:
 HPN and Liver Ca- maternal
 Prenatal History
0 Born:
0 G1P0
0 18yo
0 PNC @ 1mo
0 Regular PNC
 Natal History
0 Pre-term @ 36wks
0 NSD
0 PSH
0 BW: 4lbs
0 Rank: 1/2
 Post Natal
0 Breastfed: 1 mo
0 Weaning: 6mo
0 Immunizations: Hep B, OPV3, DPT, BCG, Hib, MMR,
RotaV

0 Currently Grade 3
 History of Present Illness

0 Px was noted with heart murmurs at birth

0 Pedia consult done
0 No further management was adviced
 History of Present Illness
5 yrs PTA
0 Diagnosed case of PDA @ 4yo
0 2d-echo
0 Exacerbation of asthma was noted
0 Surgery was not urgently done
- 1st pedia physian noted decrease of heart mumurs
0 Bothered opted for 2nd opinion
- advice: urgent surgical management ASAP
- annual ff-up check-up
- Last attack :2mo PTA
0 3 days PTA
0 Last ff-up check-up done with pedia physician
0 Referred to cardio-surgeon for contemplated surgery
0 Hence this admission
 Physical Examination
0 General Survey:
• Awake, conscious and coherent, ambulatory, not in acute
respiratory distress
0 V/S:
• Temp: 36.6˚C
• RR: 20 cpm
• PR: 128 bpm
• B/P: 90/60 mmhg
• O2 sat: 98%
0 Anthropometrics:
• Ht = 123cm
• Wt= 26.6 kg
• BMI= 17.58 kg/m2
0 SKIN
0 Inspection
• Skin is fair in color
• No cyanosis or jaundice
• No edema

0 Palpation
• Skin is warm
• Good turgor
0 HEENT
0 Head & Scalp
Inspection
• Face symmetrical
• normocephalic and atraumatic
• Head midline of the body
• Black and evenly distributed hair
• No nits, flakes, or dirt on the scalp

Palpation
• Hair is coarse
• No mass
0 Eyes
0 Inspection
• Eyebrows symmetric and evenly distributed
• No ptosis
• Anicteric sclera
• Pinkish palpebral conjunctiva
0 Ears
0 Inspection
• Symmetric auricles with no lesion
• No deformities and cutaneous lesions
• Pinna is at the level of the inner and outer canthus of the eyes
• No ear discharge

0 Palpation
• Tenderness not noted
• No lump
0 Nose
0 Inspection
• Symmetric external nose
• Nasal septum at midline and intact
• Pinkish nasal mucosa
• No alar flaring
• No bleeding nor discharge

0 Palpation
• No sinus tenderness
• Nose bridge smooth and intact with no tenderness
 
0 Mouth and Throat
0 Inspection
• Moist and pink lips
• No crack, ulcer nor blister
• Pinkish oral mucosa and gums
• Tongue at midline
• uvula at midline
• Non-hyperemic and swollen tonsils
0 Neck
0 Inspection
• No mass
• Trachea at midline
• Neck veins not distended
0 Palpation
• No lymphadenopathy
• Thyroid gland not palpable
0 Auscultation
• Bruit sounds not heard
0 CHEST AND LUNGS
0 Anterior and Posterior Thorax
0 Inspection
• Symmetrical thorax
• No lesion, lump, and mass
• No chest deformity
• No retraction

0 Palpation
• No signs of tenderness and no mass
• Equal chest expansion
• No chest lag
0 Percussion
• Resonance at both lung fields, no dullness 
0 Auscultation
• Clear breath sounds
0 CARDIOVASCULAR SYSTEM
0 Inspection
• PMI @ 5th – 6th ICS, MCL

0 Palpation
• No Palpable heaves or thrills
• No tenderness

0 Auscultation
• DHS
• Continuous murmur, machinery-like
0 ABDOMEN
0 Inspection
• Flat
• Umbilicus at midline
• No visible veins
• No visible peristalsis and pulsation
• No rash or hyperpigmentation
0 Auscultation
• Normoactive bowel sounds
• No bruits

0 Percussion
• Tympanitic at all quadrants

0 Palpation
• Non tender
• No organomegaly
0 PERIPHERAL VASCULAR SYSTEM
0 Inspection
• Pinkish nailbeds
• capillary refill of <2 seconds
• Cyanosis not noted
• No edema

0 Palpation
• Upper and lower extremities are warm to touch
• Strong peripheral equal pulses
0 MUSCULOSKELETAL SYSTEM
0 Inspection
• No trauma
• No Deformities
• Full range of motion
• No swelling of joints

0 Palpation
• Good muscle tone
• No muscular atrophy
• No tenderness on shoulders, arm, knees or hips
0 NEUROLOGIC EXAMINATION
0 Mental Status:
• awake and conscious
• oriented to place, person and time
0 Cerebrum
• Appearance: quiet, calm and aware
• Affect: Appropriate for the situation 
0 Cerebellum
• Coordinated movements
• No ataxia or tremors
0 Motor
• (-)spasticity
• (-)flaccidity
• Good muscle bulk and tone
• Normal range of motion
• Motor strength of 5/5 – normal, full strength
0 Sensory
• Change of facial expression and withdrawal from pain stimulus
• Responds to light touch
0 Cranial Nerves
• I - Not tested 
• II, III- Pupils are equally round and reactive to light and
accommodation;intact direct and consensual pupillary light reflex
• III, IV and VI- intact extraocular muscle function
• V
Motor: Intact temporal and masseter strength; clenches teeth
Sensory: Able to react to light touch
• VII – no facial asymmetry; Can close both eyelids, changes in facial
expression
• VIII - intact and able to respond when called by his name
• IX and X
Able to swallow water
• XI
Can turn head on both sides
Can shrug shoulders
• XII
Tongue protrusion at midline, no deviation
0 Autonomics:
0 Warm skin temperature
0 (+) lacrimation
0 (+) saliva and sweating
0 (+) bowel function
0 (-) cold or heat intolerance
 Salient features
History PE
9 years acyanotic
Male PMI @ 5th-6th ICS, MCL
G1P1 (+) continuous mumur, machinery-
like
36 weeks
(+) BA x 9yrs
Diagnosed PDA @ 5yrs old
 Admitting Diagnosis
0 Patent Ductus Arteriosus
Case Discus
s ion
 FETAL
CIRCULATION

3 shunts:
Ductus venosus
Foramen ovale
Ductus arteriosus
 ANATOMY
• DUCTUS ARTERIOSUS
– 6th aortic arch
– Extends: main or left
pulmonary artery to the
upper descending aorta,
distal to left subclavian artery
– Infancy
• length : 2-8mm
• Diameter: 4-12mm
• PGE2 and PGI2
– Maintains maximal patency
at fetal period
• Rise of oxygen tension
– Main stimulus of ductal
closure
– 10-15h postnatal
– Anatomic closure 
LIGAMENTUM ARTERIOSUM
PROLONGED PATENCY
- delayed closure of the ductus

PERSISTENT PATENCY
- failure of closure
 Natural History
• Incidence: 1 in every 2000 births
• Persistent patency: FEMALES (2:1)
• Cause of death:
1. CHF
2. Respiratory infection
CLINICAL MANIFESTATION AND DIAGNOSIS

PE
• hyperdynamic circulation with a widened
pulse pressure and a hyperactive precordium
• Systolic or continuous murmur ( machinery)
• acyanosis
CXR
• increased pulmonary vascularity or
cardiomegaly

ECG
• LV strain,
• left atrial enlargement,
• and possibly RV hypertrophy
2D-echo
-the patency of the ductus
-estimates the shunt size

Cardiac catheterization
-necessary only when pulmonary
hypertension is suspected
 THERAPY
Premature
• INDOMETHACIN or IBUPROFEN

Term
• Mechanical closure
– Surgically or catheter-based therapy
SURGICAL CLOSURE
-open approach
- video-assisted approach
 Open approach
• Posterior lateral thoracotomy in 4th or 5th
intercostal space on the side of the aorta (left)
• Lung is retracted anteriorly

• Neonate:
-ligated with surgical clip or permanent suture
• Older:
- triply ligated
Video-assisted thoracoscopic occlusion

Preterm and children

• Thoracoscopic technique
Older (>5yrs) and small ducts (<3 mm)
• Coil occlusion
 OUTCOMES
Premature infants
• Low surgical mortality
• hospital death rate is a consequence of other
complications of prematurity

Older infants and children

• Mortality: <1%