A 5-year old boy was brought to the ED because
A 5-year old boy was brought to the ED because of easy fatigability and difficulty of breathing of one week duration. He was apprently well at birth and up to 3 months of age when he was noted to have feeding fatigue and eventually showed failure to gain weight. Prior to these symptoms and signs, the baby can consume 5 ounces of milk formula every feeding without any discomfort. No consultation was done until after 3 months later, when the infant had coughing episodes and more pronounced breathing difficulty prompting consult. A diagnosis of congestive heart failure was given and he wa managed accordingly. Maintenance medications were continued, however, the supply of medicines became scarce and the patient took these meds irregularly. At 5 years of age, he weighed 15 kg, heart rate: 130 bpm, respiratory rate: 32/min. BP : 85-90 mmHg systolic/ 60 mmHg diastolic, Peripheral O2 sat: 94% room air. Pertinent PE findings: Carried by mother, prefers sitting up, pale (+) alar flaring, neck vein engorgement Chest: precordial bulge, PMI 5th ICS LMCL, no thrill, S2 split, S1 audible, grade 2-3/6 holosystolic murmur LLSB radiating to xiphoid area Lungs: harsh breath sounds with diminished breath sounds, right basal and wheezes, both lung base (right and left) Abdomen: globular with palpable liver edge 5 cm below subcostal area R Pulses: fairly palpable Extremities: with bipedal edema Questions: 1. Identify abnormal findings in the history and PE 2. What are the additional information needed? 3. Enumerate differential diagnoses (2-3) 4. What is the working diagnosis? 5. What laboratory tests will you request and why? 6. How will you manage this 5-year old boy? 7. What is the prognosis: treated or not treated? 8. Can you recommend some preventive measures to reduce complications or recurrence?
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