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Dyspnoea History #4

PATIENT INFORMATION

Tim is a 5 year old boy brought to the paediatrician by his mother Heather who is concerned that he seems to be getting very short of breath when playing at home. His prep teacher has also commented that Tim struggles to keep up with the other children due to his shortness of breath.

CANDIDATE INSTRUCTIONS

You will have 8 minutes to perform the following:

  1. Perform a history of the patient based on their presenting complaint (4 minutes). Some of the past history has been provided to you below.
  2. Interpret examination findings and provide a top differential diagnosis (1 minute)
  3. Outline further investigations and management to Heather (Tim’s mum) (3 minutes)
Medications None
Medical conditionsNo current medical conditions, however had one hospital visit for croup at the age of 2
AllergiesNone
Family History Not significant
Social History Just started prep this year, was in kindergarten for last 2 years – no specific issues

TASK 1 – HISTORY (4 MINUTES)

History of presenting complaint

Tim has been getting short of breath whenever he runs around at school.

  • Onset: Exertional, especially at school when he's playing with other children
  • Time course/duration: Has likely been going on for awhile but has only really noticed this when he started prep. He started running around more
  • Exacerbating/relieving factors: Excercise
  • Beliefs: Tim has had pneumonia 4x – could that have permanently damaged his lungs?
    • Usually relatively un-complicated
    • Gets antibiotics from GP
    • No admissions to hospital for pneumonia
    • Sx of productive cough, fever and SOB

Systems review/risk factors

  • 4 marks for asking about differentials from at least 3 different systems AND asking about red flags
  • 3 marks for asking about differentials from at least 3 different system

Symptoms in BOLD indicates positive answers, other answers are suggestions of what is required in terms of questioning.

Asthma:

  • No wheeze
  • No cough
  • No other atopic conditions
  • No chest pain

Viral Induced/Post-Viral:

  • No recent or current fevers
  • No coryzal symptoms
  • He seems well

T1DM: Diabetic ketoacidosis:

  • No Increased thirst
  • No polyuria
  • Weight loss

ASD/VSD:

  • Small usually asymptomatic
  • Larger defects: exercise intolerance and poor weight gain
  • Recurrent chest infections

Note: Cyanotic heart disease -> tetralogy of fallot, transposition of the great arteries

  • presents with cyanosis in neonatal stage
  • acute episodes of hypoxia -> children stop and squat (tet spells)

Obstetric history

  • Mother G2P2
  • Normal vaginal birth
  • No medical complications during pregnancy
  • No abnormalities on scans
  • Nurse mentioned something about heart during baby check but mentioned it would probably pass – cannot recall what she said
  • No in-hospital treatment post birth

Growth and Development

All developmental milestones met

Normal height but tracking slightly below percentile since

  • 50% percentile for height
  • 25% for weight
  • Has always been on the lighter side
  • Born at 32% and tracking down over last few years

TASK 2 – INTERPRET EXAMINATION FINDINGS (1 MINUTE)

Atrial Septal Defect

Examination Findings

Vitals

  • HR 130
  • BP 90/75
  • O2 sats: 99%
  • RR: 35
  • T 37.2

General Inspection

  • 5 year old boy of average height but moderately thin. Does not seem short of breath at rest when sitting in the GP office. Seems mildly fatigued/tired.
  • Growth – 52% for height and 24% for weight

Respiratory:

  • Clear – Bilateral air entry, no wheeze, no crackles
  • No dullness to percussion
  • No hand findings eg. clubbing

CVD:

  • Normal JVP
  • Ejection systolic murmur at left sternal edge
  • Fixed, wide split second heart sound
  • No heaves or thrills
  • No peripheral findings

TASK 3 – FURTHER INVESTIGATION AND MANAGEMENT (3 MINUTES)

Investigations

  1. Referral to a paediatric cardiologist
  2. Organise an echo to definitely diagnose ASD
  3. May also organise CXR (probably not given young age) and ECG to look for associated cardiac findings. e.g. right ventricular hypertrophy and increased pulmonary vasculature

Management – Depends on size of defect, location and symptoms

  1. Size: Less than 0.5cm will usually close spontaneously, above 1cm usually requires surgical correction
  2. Type:
    • Secundum: defect in foramen ovale -> cardiac catheterisation and insertion of an occlusive device
    • Partial primum: defect in atrioventricular septum above AV valve -> depends on size and symptoms – may leave for spontaneous closure or surgical management
  3. Symptoms:
    • Left to right shunting
    • right heart enlargement
    • pulmonary HTN
    • dysrhythmia
  4. Long term follow up:
    • indicated post surgical or transcatheter ASD closure
Total:

REFERENCES

https://www.msdmanuals.com/en-au/professional/pediatrics/congenital-cardiovascular- anomalies/atrial-septal-defect-asd

https://www.uptodate.com/contents/isolated-atrial-septal-defects-asds-in-children- classification-clinical-features-and- diagnosis?search=atrial%20septal%20defect%20&source=search_result&selectedTitle=1~15 0&usage_type=default&display_rank=1

https://www.ncbi.nlm.nih.gov/books/NBK535440

https://www.uptodate.com/contents/isolated-atrial-septal-defects-asds-in-children- management-and- outcome?search=atrial%20septal%20defect&source=search_result&selectedTitle=4~150&u sage_type=default&display_rank=4#H2433848213