CASE REPORT

TETRALOGY OF FALLOT
Compiled by :

Ayu Yusriani Nasution (120100013)

Nur Azimah Bt. Nor Mohhemmad (110100416)

Pembimbing :dr. Johannes H. Saing, Sp.A(K)

INTRODUCTION
Tetralogy of Fallot is cyanotic type of
congenital heart disease, that consists of 4
anomalies in cardiac structure.
Incidence of this type of CHD is 10-15% of all
congenital heart disease, and is 2/3 of
cyanotic congenital heart disease, with
different incidence on each country.

Heart with Tetralogy of

Fallot

CASE

HISTORY OF DISEASE
MAZ, a boy, 3 years and 2 months old, with
body weight 10 kg and body height 90 cm,
was admitted to Haji Adam Malik Central
General Hospital Medan on 02nd August 2016
at 11.00 a.m. with a main complaint of
dypsnoe and sianosis. The main complaint
was experienced since the last 3 days and
became severe.

HISTORY OF DISEASE (CONTD)

History of dypsnoe dan sianosis (+) since he
was 1 month old, during lactation and gone
with some rest and medicine.
He brought to RSUP Haji Adam Malik when he
was 6 months old, and was diagnosed with
congenital heart disease.

HISTORY OF DISEASE (CONTD)

Cough (+) 3 days a go, Fever (-), history of
fever (+), recurrent about 1 months before
being admitted to the hospital, chilling (-).
Nausea (-), vomit (-).
History of chest pain and pretibial oedema (-)
Urination and defecation was normal.

OTHER HISTORIES
History of Previous Disease :
Tetralogy of Fallot.
History of Medication :
Paracetamol syrup
Not clear

OTHER HISTORIES (CONTD)

History of Familys Disease :
None
History of Family Medication :
None

OTHER HISTORIES (CONTD)

History of Pregnancy :
The age of the patients mother was 25 years
old during the pregnancy. History of getting
pain, fever, hypertension, diabetes melitus,
and medication during pregnancy were
denied by his mother.

OTHER HISTORIES (CONTD)

History of Birth :
The patient was born spontaneously
pervaginam, assisted by a midwife. The
patient is the firts child. Crying immediately
after birth. Body weight at birth was 3000
grams, with 50 cm body length and unclear
head circumference. Cyanosis and jaundice
were not found at birth.

OTHER HISTORIES (CONTD)

History of Feeding :
0-6 month : breast feeding
6-12 months : breast feeding and milk
porridge
> 12 months
rice

: breast feeding and steamed

OTHER HISTORIES (CONTD)

History of Immunisation:
completed, Hep. B 3x, BCG, Polio
4x, DPT 3x, Campak 1x.
History of Growth and
Development :
Lifting head
months

:3

Turn over body : 5

months

Standing: 12 months
Walking : 14 months
Talking

: 12 months

PHYSICAL EXAMINATION
Presence Status :
Sensorium
Mentis

: Compos

Nutrition Status :
Body weight

GCS : 15 (E4 M6 V5)

Body height

BP

: 90/50 mmHg

Weight-for-age

HR

: 112 bpm

RR

: 26 pm

Stature-for-age
z < 0)

T : 36,8 C

: 10 kg
: 90cm
: 71% (z < -3)
: 93 % ( -2 <

Weight-for-stature : 83% (z < -3)

Ane (-), Ict (-), Cya (+), Dys (+),

PHYSICAL EXAMINATION
(CONTD)
Localized Status (contd) :
Head :
Shape : Normal.
Face
Eye

: Edema (-).

: Light reflex (+/+), isochoric pupil, pale

inferior conjunctiva palpebra (-/-), icteric
sclera (-/-).

E/N/M : WNL/WNL/WNL.

PHYSICAL EXAMINATION
(CONTD)
Localized Status (contd) :
Neck
: Lymph node enlargement (-).
Thorax
:
Inspection
: SF, retraction (+).
Palpation
: Normal tactile fremitus, right = left.
Percussion
: Normal resonance.
Auscultation
: Vesicular, RR : 26 pm, regular, rh (-/-),
wh (-/-).

Heart

: S1 and S2 heart sound (+) normal,

PHYSICAL EXAMINATION
(CONTD)
Localized Status (contd) :
Abdomen : Soepel, peristaltic (+) normal, liver,
spleen, and
mass are not palpable.
Extremities : Pulse : 112 bpm, regular, adequate
p/v, warm
skin, CRT < 3 seconds, edema (-),
clubbing
fingers (+).
Anogenital : Male, penis (+), testis (+), within
normal limit.

LABORATORY
EXAMINATION
Complete Blood Count and RFT (2nd August
2016 / 16.32)

Test Type
Hemoglobin
Erythrocyte
Leucocyte

Result
15,5
8,14
8,340

Unit
g/dL
million/L
/L

Thrombocyte

467,000

/L

53
65
19
29,1

%
fL
pg
g/dL

Reference Value
13 18
4.50 6.50
4,500 13,500
150,000
450,000
39 54
81 99
27.0 31.0
31.0 37.0

0.40
1,80
54,60
34,40
8,80

%
%
%
%
%

0.00 1.00
1.00 3.00
50.00 70.00
20 50
2.00 8.00

Hematocrite
MCV
MCH
MCHC
Differential Count

Basophil
Eosinofil
Neutrophil
Lymphocyte
Monocyte

Test Type
Blood Urea Nitrogen
(BUN)
Ureum
Creatinine
GFR

Result

Unit

Reference Value

mg/dL

9 21

15
0.34

mg/dL
mg/dL
mL/min/1.73
m2

19 44
0.7 1.3

55.96

96.5 136.9

DIAGNOSIS
Differential Diagnosis

: 1. Tetralogy of Fallot

2. TGA
Working Diagnosis

: Tetralogy of Fallot

THERAPY
Activity : Bed rest
Therapy : O2 1 liter/ menit via nasal canule

IVFD RL 4 cc/ hour

Propanolol 2 x 6 mg
Laxadyn syr 3 x cth II

PLANNING ASSESMENT
AGDA
Electrocardiography
Echocardiography
Kateterization

FOLLOW UP

3rd Agust 2016 - 07.00 a.m

S

Cyanosis (+) Dispnue (+)

Sens : CM t : 37,3oC BB : 10 kg TB: 90 cm

Head :
eyes : RC (+/+), pupil isokor, pale conjunctiva inferior palpebra (-/-)
T/H/M:N/N /cyanosis (+)
thorax: SF, retraksi (-)
HR: 112x/min, regular, murmur (+) sistolik
RR: 26x/min, regular, ronchi (-/-)
Abdomen: soepel, peristaltik (+) N, H/L : not detected
Extremitas : Pulse: 112x/min, t/v enough, clubbing finger (+), pretibial oedem (-)
Fotothoraks :
The impression RVH with the apex raised , the waist of the heart not prominent, boot shape
Ekokardiogram :
RVH

Cyanotic CHD ec 1. Tetralogy of Fallot

2. Transposition of Great Artery
IVFD RL 4cc/ hours
Propanolol 2x6 mg
Laxadyn syr 3 x cth II (k/p)
Rencana : echocardiography

4th Agust 2016 - 07.00 a.m

S

cyanotic(+) Dispnue (-)

Sens: CM t : 36,9oC BB: 10 kg TB: 90 cm

Head :
Eyes :RC (+/+), pupil isokor, Pale conjunctiva inferior palpebra (-/-)
T/H/M:N/N/Cyanotic(+)
Thorax : SF, retraksi (-)
HR: 100x/min, regular, murmur(+) sistolik
RR: 24x/min, regular, ronchi (-/-)
Abdomen: soepel, peristaltik (+) N, H/L : not detected
Extremitas : Pulse: 100x/min, t/v enough clubbing finger (+), pretibial oedem (-)

Cyanotic CHD ec Tetralogy of Fallot

IVFD RL 4cc/ hours

Propanolol 2x6 mg
Laxadyn syr 3 x cth II (k/p)
Plan : Catheterization at 11.00am

5th Agust 2016 - 07.00 a.m

S

cyanotic(+) Dispnue (-) Fever(+)

Sens: CM t: 38,1oC BB: 10 kg TB: 90 cm

Head :
Eyes : RC (+/+), pupil isokor , Pale conjungtiva inferior palpebra (-/-)
T/H/M:N/N/Cyanotic(+)
Thorax: SF, retraksi (-)
HR : 104x/min, regular, murmur(+) sistolik
RR: 38x/min, regular, ronchi (-/-)
Abdomen: soepel, peristaltik (+) N, H/L : not detected
Extremitas : Pulse: 104x/min, t/v cukup, clubbing finger (+), pretibial oedem (-)

Cyanotic CHD ec Tetralogy of Fallot

Post Kateterisasi :
IVFD D5% Nacl 0.45% 4cc/ hours
Parasetamol 3x120 mg
Propanolol 2x6 mg
Laxadyn syr 3 x cth II (k/p)
R/ Refer for total correction

6th Agust 2016 - 07.00 a.m

S

cyanotic(+) Dispnue (-) Fever(-)

Sens: CM T: 36,9oC BB: 10 kg TB: 90 cm

Head :
Eyes : RC (+/+), pupil isokor , Pale conjungtiva inferior palpebra (-/-)
T/H/M:N/N/Cyanotic(+)
Thorax: SF, retraksi (-)
HR : 104x/min, regular, murmur(+) sistolik
RR: 38x/min, regular, ronchi (-/-)
Abdomen: soepel, peristaltik (+) N, H/L : not detected
Extremitas : Pulse: 100x/min, t/v cukup, clubbing finger (+), pretibial oedem (-)

A
P

Cyanotic CHD ec Tetralogy of Fallot

IVFD D5% NaCl 0,45% 4cc/ hours
Propanolol 2x6 mg

Laxadyn syr 3 x cth II (k/p)

R/ PBJ

DISCUSSION

Tetralogy of Fallot is one of cyanotic congenital heart

disease which consist of 4 anomalies on the cardiac
structure. In this patient, those anomalies were confirmed
by echocardiography procedure.
Interpretation of Echo : Hyperthrophy of RV, severe
infundibular PS, large, malalignment of VSD, and
overriding aorta.
Conclusion and Diagnosis : Tetralogy of Fallot

From the physical examination, cyanosis on lips and clubbing finger

were found.

ChestX-Ray

Electrocardiogram

Management Therapy
1.Meletakan pasien dalam posisi menungging (knee
chest position),
sambil mengamati bahwa pakaian yang melekat
tidak sempit
2.Pemberian O2
3.Koreksi asidosis metabolik dengan NaHCO3
4.Pemberian propanolol 0,1 mg/kgBB intra vena
5.Pemberian morfin subkutan atau IV 0,1 mg/kgBB

SUMMARY
MAZ, 3 year 2 months old boy, that weighted 10 kg
and lengthed 90 cm, was admitted to Pediatric
Department Unit in H. Adam Malik General Hospital
Medan on August 2nd 2016 with main complaint was
dyspnoe and cyanosis since 3 days before hospital
admission. He is diagnosed with Tetralogy of Fallot.
Patient is treated with propranolol 2x6 mg and
Laxadyn syr 3 x cth II (k/p).

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