Tetralogy of Fallot

Informer – Mother (relation)

2 years old male child from West Bengal (place) presented with chief complaints of-

-    Bluish discolorationof lips since 1 year

-    Easy fatiguability since 1 year

History of Present Illness –Child was apparently asymptomatic till 1year back when mother noticed his lips turning blue when the child played. The bluish discoloration was relieved / reduced  when the child took  rest.She also noticed that her son became tired early and could not play for as long as other children of his age could play since last 1 year. She also gives history of her son adapting the ‘namaaz’posture whenever the child feels excessively tired and he seemed to improve after acquiring such a posture.

No h/o dysnea on exertion 

No h/o loss of consciousness 

No h/o bluish discoloration on anywhere else in the body 

No h/o seizures 

No h/o related to respiratory tract infections 

No h/o prolonged fever

No h/o difficulty feeding or getting tired while feeding 

No h/o hemoptysis 

No h/o pain abdomen 

No h/o developmental delay

No H/O previous cyanotic spell/ hospital admission 

Past H/O = No H/O pulmonary kochs/ bronchial asthma 

Drug H/O =Nil

Personal H/O = child has decreased appetite,normal  bowel / bladder habits.

Developmental H/O = child has attained all milestones proportional for his age 

Family H/O – non- consanguineous marriage, he is the only child.No any other member in the family  has similar condition.

Brith H/O -  born by Caesarean section due to non- descent of head and non progress of labor.Baby cried immediately after birth.

  Diagnosis from History: Congenital Heart Disease- Cyanotic child with right to left shunt

General Examination –

Child is conscious & co- operative moderately built & nourished

Examination done in lying down position in bed 

Pulse = 100/min normal character/volume, condition of vessel wall normal, no radioradial or radiofemoral delay.

BP – 90/50mmHg in left upper limb in supine position 

RR – 22/m regular.

Afebrile,no pallor,icterus, lymphadenopathy, pedal oedema

Clubbing-grade2

Peripheries warm *

JVP- not raised

Spo2 on air 83%

Systemic Examination -

CVS – Inspection –

Precordium- chest in symmetrical, no dilated veins or scars seen

Apex impulse is visible in left 5thintercostal space just medial to midclavicularline, no other pulsations visible.

Palpation -  Apex beat palpable in left 5thintercostal space  medial to midiclavicular line .

-    Systolic thrill in left 2nd ICS 

-    No parasternal heave felt

-    No any other pulsations felt

Percussion – Right heart border corresponds to stenum, Left heart border corresponds to apex, Pulmonary area  is resonant.

Auscultation –

-    Mitral area = S1S2 heard no murmur 

-    Aortic area = S1S2 heard no murmur 

-    Tricupid area = S1S2 heard  no murmur 

-    Pulmonary area = Ejection systolic murmur, crescendo-decrescendo, grade 4/6 present

-     Single S2 heard, no conduction 

-    No murmur heard in the interscapular area

Respiratory system - vesicular  breath sounds heard all over chest

Per Abdomen – liver dullness present in right 5th ICS note on Lf side, no organomegaly

CNS – no focal neurological deficit, no motor sensory deficits, higher functions normal. 

  

 Diagnosis – Cyanotic congenital heart disease, Tetralogy of Fallot physiology, most probably TOF not in failure, in sinus rhythm, no evidence of infective endocarditis.