GULU UNIVERSITY MEDICAL JOURNAL

Gulu University Medical Journal (GUMJ) 2009/2010 Vol 5.
1. A diagnosis is most likely not possible at this stage
because history is not adequate. Though she may
have a few rough ideas in mind.
Possible impressions could be;
• Pneumonia in view of the cough associated with
difficulty in breastfeeding.
• Febrile illness in view of the fever for example
malaria and bacterial meningitis.
• Anaemia in view of difficulty in breathing.
2. At this stage she has only been able to ascertain
the presenting complaint, history of presenting
complaint, review of other systems. So she has to
inquire more about other aspects of the history and
examine the patient to be sure of the diagnosis.
3. Right from the beginning as Dr Doreen gets
engraved into a conversation with the patient’s
mother, you have to keep in mind important aspects
like DIB * 4/7 and cough *3/7. It’s important to
note that the DIB is not worsened on lying down
and no h/o body swelling. As you proceed, it’s
wise to ask yourself a few questions like: why is
the child always in and out of health facilities? ,
what does the ‘hole in the heart” imply?
Other aspects are that she delivered from home; the
child’s birth was preterm and she was under weight.
She was breastfed less than the recommended 6
months, and does not feed adequately.
4. From the history and examination results, the child
most likely has a congenital heart disease (CHD).
5. The diagnosis is Ventricular Septal Defect (VSD).
Congenital means existing before or at birth.
Congenital heart diseases can be classified according
to whether they cause cyanosis or characterized by
presence of a shunt.
They can present with a heart murmur (which Lamunu
had), heart failure or cyanosis. Examination revealed no
cyanosis. Hence the condition is acyanotic. The shunt
can be at the atrial wall or the ventricular wall level.
Lamunu has ventricular septal defect with a left to
right shunt.
Defects of the ventricular septum are the commonest and
usually occur as isolated defects and as one component
Quiz Answers
of a combination of anomalies. The opening is usually
single and situated in the membranous portion of the
septum i.e. perimembranous (75%). Malalignment
defects may due to malalignment of infundibular
septum and trabecular muscular septum; muscular
defects may be located anywhere in the muscular
septum (5-20%). Presentation depends primarily on
defect size and status of the pulmonary vascular bed,
rather than on the location of the defect.
Shunting depends on the relative pulmonary and
systemic vascular resistance. In large defects there is
equilibration of right and left ventricular pressures. A
large VSD with a low pulmonary resistance, degree of
left to right shunt is increased.
Usually large defects come to medical and, often,
surgical attention very early in life. Natural history
of ventricular septal defect ranges from spontaneous
closure to congestive cardiac failure (CCF) and death
in early infancy. The patient’s defect is of moderate
size and spontaneous closure has not taken place and it
could be that she has developed in view of the dyspnea,
little interest in playing and difficulty in B/F. Among
others are the possible development of pulmonary
vascular obstruction (more with large) defects, Right
Ventricular (RV) outflow tract obstruction, aortic
regurgitation, and infective endocarditis.
Lamunu’s DIB and cough indicate pulmonary
hypertension though no haemoptysis as yet, though
no worry for severe pulmonary vascular obstruction
(Eisenmenger Syndrome) which usually presents with
symptoms in adult life including exertional dyspnea,
chest pain, syncope, and haemoptysis. Thus, the
importance of correcting moderate-large defects
surgically early in life when pulmonary vascular
disease is still reversible or not yet developed. The
right-to-left shunt leads to cyanosis, clubbing, and
erythrocytosis. In all patients, the degree to which
pulmonary vascular resistance is elevated before
operation is a critical factor determining prognosis.
If the pulmonary vascular resistance is one-third or
less of the systemic value, progression of pulmonary
vascular disease after operation is unusual. However,
for a moderate to severe increase in pulmonary
vascular resistance preoperatively, either no change or
a progression of pulmonary vascular disease is common
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