Q 1:
Included in your rounds today is a 36-hour-old boy who was born at term by normal, spontaneous vaginal delivery. His respiratory rate is 80 breaths/min and heart rate is 168 beats/min. He has easily palpable, bounding pulses in all four extremities, and his blood pressure is 72/30 mm Hg. Precordial examination reveals a lift and a 3/6 systolic ejection murmur at the upper left sternal border . You also note a murmur over the anterior fontanelle. Of the following, the MOST likely diagnosis is
A. aortic coarctation with congestive heart failure
B. aortic insufficiency
C. large ventricular septal defect with congestive heart failure
D. left-to-right extracardiac shunting with congestive heart failure
E. right-to-left extracardiac shunting with right heart failure
Anwer
D
The newborn described in the vignette has physical findings and blood pressure that
suggest a run-off lesion from the aorta, which could be significant aortic insufficiency, a largevolume
ductus arteriosus, or an arteriovenous malformation. There is no diastolic murmur to
suggest aortic insufficiency, and at 36 hours of age, a ductus arteriosus would not be expected
to lead to symptoms. Similarly, a large ventricular septal defect might present with a holosystolic
murmur and rarely leads to symptoms in the first few days after birth. Coarctation often leads to
narrowed blood pressure and is associated with a pressure load on the left ventricle rather than
a volume load, as in this patient. Right-to-left extracardiac shunting can occur only when
pressure in the venous (right) vessel exceeds that in the arterial (left) vessel. This is a situation
that does not exist.
Anwer
D
The newborn described in the vignette has physical findings and blood pressure that
suggest a run-off lesion from the aorta, which could be significant aortic insufficiency, a largevolume
ductus arteriosus, or an arteriovenous malformation. There is no diastolic murmur to
suggest aortic insufficiency, and at 36 hours of age, a ductus arteriosus would not be expected
to lead to symptoms. Similarly, a large ventricular septal defect might present with a holosystolic
murmur and rarely leads to symptoms in the first few days after birth. Coarctation often leads to
narrowed blood pressure and is associated with a pressure load on the left ventricle rather than
a volume load, as in this patient. Right-to-left extracardiac shunting can occur only when
pressure in the venous (right) vessel exceeds that in the arterial (left) vessel. This is a situation
that does not exist.
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