Download PFO case study

NUR 580
CASE STUDY
Atypical Presentation of Congenital Anomaly
CHIEF COMPLAINT

“I’ve been sick for a few weeks now with this
sinus thing and I’m having shortness of breath
from it.”
HISTORY OF PRESENT ILLNESS

17 yo female presents to her PCP office with:

SOB/Chest tightness
Times one week following treatment of URI
 Gradual onset
 Decreased with with rest
 Exacerbated by any prolonged (more than 5 minutes)
activity such as walking
 Severity a 7/10 at its worst and 2/10 at baseline
 No pain involved
 Never occurred before
 Has lasted for one full week
 Went to ER day prior to this office visit and left after
waiting for 7.5 hours.

HPI CONTINUED….
Patient developed “chest tightness” that does not
radiate and is brought on with previously
described SOB. Cannot rate a pain intensity to it
as she states “it doesn’t really hurt, it’s just weird
when I’m really breathing hard after like walking
to the office here.”
 Went to ER for this same complaint yesterday
and sat in waiting room with her mom for 7.5
hours before leaving to go home.

HPI CONTINUED….

Patient was also treated with Z-pak x5 days and
Augmentin x10 days prior to onset of the current
symptoms and previously tested positive for the
flu following 5 days of symptoms.
R.O.S.

General:

No:
Changes in appetite
 Weight loss


Denies:
Fever
 Weakness
 Fatigue


Skin:

Denies:
Rashes
 Lumps
 Sores
 Itching
 Dryness
 Changes in color of:
 Hair
 Nails

R.O.S.

Head:

Denies:

Ears:

Dizziness
 Lightheadedness
 Headache


Eyes:

Denies:
Blurred/double vision
 Spots/specks
 Flashing lights
 Excessive tearing


Does not wear
corrective lenses

Denies:

Hearing loss

Tinnitus

Vertigo

Earaches

Infection

Discharge
Nose/Sinuses:

Denies:

Itching/sneezing/bleeds

Sinus pain/congestion

Treated for URI more
than 10 days ago
R.O.S.

Throat:

Denies:
Bleeding gums
 Frequent sore throats
 Sore tongue
 Dry mouth
 Hoarseness



Last Dental Exam x8
months prior.
Neck:

Denies:

Swollen
glands/lumps/pain/stiffn
ess in neck

Breasts:


N/A
Respiratory:


Denies:

Hemoptysis

Wheezing
Complains of:


Dyspnea on
exertion
Cough occassionally

Dry

Non-productive
R.O.S.

Cardiovascular:

Denies:
Rheumatic fever
 Murmurs
 Palpitations
 Orthopnea
 Edema


Complains of:



Chest pressure (see
HPI)
No recent blood work
or ECG
GI/GU:
N/A
Peripheral Vascular:
 N/A
Urinary:
 N/A
Genital:
 N/A
Musculoskeletal:
 Denies:
 Trauma to chest
 Manually reproducible
pain
 CP reproducible with
deep
inspiration/movement





R.O.S.

Psychiatric:


Neurologic:


N/A
N/A
Hematologic:

Denies:
Anemia
 Blood dyscrasias


Endocrine:

N/A
PAST MEDICAL HISTORY

General:


Allergies:


Not being medically treated for anything at this present
time.
None
Medical Illness:
Recently treated for URI that did not respond well to
treatment and original symptoms have since dissipated
and left with complaints of SOB/CP as described in HP.
 Denies:



HTN, MI, CHF, COPD, Asthma, Cancer
States had some heart defect as a child that resolved itself
in a a few days.

Mother states it was VSD that closed on it’s own shortly after
her birth but was monitored and has not had issues with this.
Cardiology cleared her of this years ago.
PAST MEDICAL HISTORY

Accidents/Injuries:


Surgery/Hospitalizations/Transfusions:


Broke her left forearm 2 years ago during
cheerleading competition, no concerns/problems with
it now.
None reported
Immunizations:
School immunizations up to date and not on file at
the office.
 Flu Shot received this season.


Medications:

None
PAST MEDICAL HISTORY

Family History/Social History:

No:

DM, Anemia, Cancers, HTN, Cardiac anomalies/problems.
All family members alive and well.
 Does not smoke
 Has one glass of wine with family at home on special
occasions.


Occupation:

Full Time High School Student
Cheerleader
 Runs Track

PAST MEDICAL HISTORY

Insurance/Finance:


Marital Status:


Sleeps from 5-8 hours per night
Safety:


Single, no significant other
Habits:


Health insurance provided through her parents
Drives with seat belt/at posted speed.
Nutrition:

Eats home cooked meals and school lunch most of the
time, rarely eats out with friends.
PHYSICAL EXAM

General:


Vitals:


122/78 – 104 – 98.7 – 26 – 0/10 – 95% on RA
Height/Weight/BMI:


White female pleasant and cooperative, well
groomed, slim in appearance in mild respiratory
distress upon initial presentation to the office.
5’7” 118 lbs, 18.5(normal)
Skin:
Warm, pink, intact with no lesions.
 Slight diaphoresis

PHYSICAL EXAM

Head:





Normocephalic/atraumatic, symmetric
Hair dry/intact. No lesions/balding/tenderness.
No sinus pain with palpation.
Nasal turbinates pink/pale with no drainage
Eyes:





Acuity 20/20 uncorrected
Fields intact
Pupils 5mm down to 2mm, equal, round, reactive to light and
accommodation with consensual response.
Sclera clear/white bilaterally.
No:







Nystagmus
Ptosis
Proptosis
Lid lag
Swelling
Disc margins sharp, no hemorrhages or exudates, A:V ratio 2:3 and no AV
nicking. Red reflex intact.
Eye lids and lashes/brows intact
PHYSICAL EXAM

Ears:
Tympanic membranes clear/pearly gray with appropriate
landmarks
 Acuity good to whisper test


Neck:

Denies:


Tenderness with palpation
Difficulty swallowing
Trachea midline
 No pre/post auricular, tonsilar, cervical, submandibular,
submental, or supra clavicular lymphadenopathy.


Mouth/Pharynx:
Mucous membranes moist with mild erythema of uvula
and mild clear post nasal drip
 Tonsils grade 2, pink

PHYSICAL EXAM

Breasts:


N/A
Respiratory:
Thorax symmetric with good expansion
 Lungs resonant
 Breath sounds clear and equal bilaterally with no
adventitious sounds
 No

Bronchophony
 Egophony

Diaphragm descends 6cm bilaterally
 Tachypneic at rest

PHYSICAL EXAM

Cardiovascular:
S1 & S2 with no extra heart tones
 HR fast but regular


Peripheral Vascular:


GI/GU:


N/A
N/A
Musculoskeletal:
No deformity to chest wall
 No point tenderness
 No swelling


Neurological:

N/A
DIAGNOSTICS

12 lead ECG (Stat):


Blood work:







T wave inversion in septal leads
Cardiac Enzymes
D-Dimer
CBC with Diff.
CMP
Lipase
Amylase
Radiology:
Chest X-ray
 Chest CT

DIFFERENTIAL
DIAGNOSIS













ACS – Cardiac Enzymes/ECG (Serial)
Costochondritis – Treatment with NSAIDS/rest
Pulmonary Embolism – X-ray and CT will rule out
Rib Fracture – X-ray will rule out
PDA – (Typical in young children & very uncommon
finding in adults
Aortic Aneurysm – Radiology Imaging
Aortic Dissection - Radiology Imaging
Tension Pneumothorax - Radiology Imaging
Pericarditis – ECG further testing
Endocarditis
Esophageal Tear - Radiology Imaging
Pleuritis - Radiology Imaging, ECG
GERD – symptoms and ruling out all other emergent
causes of symptoms
DIAGNOSIS

Taken to local Emergency Department via
Ambulance for continual monitoring and serial
labs plus ECG. Patient followed up with PCP a
week after the incident with a diagnosis of…..
Patent Foramen Ovale

A small opening in the septum between the
atria’s.
EPIDEMIOLOGY

Prevalent in about 1 in 1,500 live births

Undetected due to lack of symptoms
Common in about 25% of the population
 No age/gender predominance

PATHOPHYSIOLOGY



During fetal circulation the PFO is a normal opening
to allow the lungs to be bypassed, however closes very
quickly after birth once the pulmonary pressures
increase.
Some PFOs do not close entirely but are so small that
they are never detected
Causes of reopening or increased symptoms are:
Pressurization injuries or rapid changes
 Viral illness with respiratory compromise
 Right atrial pressures rise:





Coughing
PE
Pneumonia
Other respiratory conditions
DIAGNOSTICS







Known cardiac defects from childhood
Agitated saline injection during Trans esophageal
echocardiogram (TEE) or Trans thoracic echo.
ECHO during coughing or major illness
ECG – Septal changes noted, prolonged PRI (enlargement of
Atria)
Ejection systolic murmur if Pulmonic valve is involved
Commonly found in deep water divers or sky diving.
Common symptoms are:







SOB with minimal exercise
CHF
CVA
Cryptogenic CVA
Abnormal ECG initially
Migraines
Cryptogenic CVA (small emboli typically go through the lungs and are
absorbed, with this malformation they go directly to the body.
SUGGESTED TREATMENT/PREVENTION



Prevention focuses on early diagnosis and treatment prior to
significant cardiac/neuro changes occur such as hypertrophy,
CVA, MI.
Correction is rarely needed as risk outweighs the benefit and
patients are usually asymptomatic
PFO repair:







Open Heart Surgery
Percutaneous implant/patch
Medical management of symptoms
Routine screening is not cost effective and is not covered by
insurance companies so costs would be out of pocket.
Screening is covered for patients who have TIAs or CVAs due
to this possibly being cardiac related.
Symptoms resolved following further treatment of cough
which was from a resolving URI.
She will be monitored by a cardiologist for worsening
symptoms
PATIENT EDUCATION

Focus is on:
S&S of peripheral arterial embolism
 CVA
 TIA
 DVT


Importance of cardiology follow-up
REFERENCES

“ASD-PFO” (2006). Retrieved from http://www.marmur.com/ASD-PFO.html

Butera, G., Romagnoli, E., Sangiorgi, G., Caputi, L., Chessa, M., & Carminati, M. (2008). Patent foramen ovale
percutaneous closure: the no-implant approach. Circulation, 116, 1701-1706.

Carroll, J. D., Dodge, S., & Groves, B. M. (2005). Percutaneous patent foramen ovale closure. Cardiology Clinics,
23, 15-33.

“Diseases and Conditions: Patent foramen ovale” (2012). Retrieved from http://www.mayoclinic.org/diseasesconditions/patent-foramen-ovale/basics/definition/CON-20028729

Fisher, D., Fisher, E., Budd, J., Rosen, S., & Goldman, M. (1995). The incidence of patent foramen ovale in 1,000
consecutive patients. a contrast transesophageal echocardiography study. CHEST,

Kerut, E., Lee, S., & Fox, E. (2006). Diagnosis of an anatomically and physiologically significant patent foramen
ovale. Echocardiography: A Journal of CV Ultrasound & Allied Tech., 239, 810-815.

Kizer, J. R., & Devereux, R. B. (2005). Patent foramen ovale in young adults with unexplained stroke. The New
England Journal of Medicine, 353, 2361-2372.

Naqvi, T., Rafie, R., & Daneshvar, S. (2010). Potential faces of patent foramen ovale. Echocardiography, 897907.

“Patent Foramen Ovale” (2011). American Heart Association. Retrieved from
http://www.heart.org/HEARTORG/Conditions/More/CardiovascularConditionsofChildhood/Patent-ForamenOvale-PFO_UCM_469590_Article.jsp

“Patent Foramen Ovale” (2013). Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/001113.htm

“Patent Foramen Ovale” (2015). Retrieved from
https://online.epocrates.com/noFrame/showPage?method=diseases&MonographId=951&ActiveSectionId=52

“PFO” (2014). Retrieved from
http://my.clevelandclinic.org/services/heart/disorders/congenital/pfo/hic_Patent_Foramen_Ovale_PFO