Student Version

The Case of Vivien Thomas

Case 10: Fall 2024
 Patient Profile
Vivien Thomas is a 6-week-old female assigned at birth with intermittent cyanosis and
fussiness who presents to the Emergency Department with her mother.

Subjective

Patient’s Visit Transcript: [Brought in by Mother]

“My name is Theresa Thomas. I’m here because I don’t think my baby is doing well. My
baby was born on September 23, 2024. I came in because she seems to be very pale when
she is crying, and I was noticing it more and more. Until this morning she was crying and
then she turned blue. She’s never turned blue before. I had asthma as a child, but this
didn’t seem like asthma. She wasn’t wheezing or anything. She just turned blue after she
was crying. And then she went limp. So, we came here to the hospital because I’ve never
seen this before. She didn’t shake or anything. And she wasn’t out for long- maybe a few
seconds.
I notice she sweats when she’s eating. I’m not sure why because we still have the
air on in the house. She stops every minute and sometimes she falls asleep while she’s
feeding. She’s my first baby, so I thought maybe I was doing something wrong with
feeding her. I’ve been bottle feeding because I tried to breastfeed the first day in the
hospital, but she just wouldn’t latch on. She was started on bottle feeding, but she still
takes a long time to eat. We’re giving her formula, specifically Enfamil; that’s what they
gave me to feed her in the hospital. It takes her over an hour just to finish an ounce. She
does cry a lot, but my family has told me that’s normal so I can be ok with that. But her
diapers, I’ve noticed that they are wet, but I’m not changing her as much as I was, and
they’re not as heavy as they were, so maybe she’s not getting enough milk. Her stools are
normal and regular … they were yellow or green colored when she was born but now,
they’re browner. I haven’t noticed any blood. She hasn’t really vomited or anything. But I
do notice that sometimes she will spit-up on occasion especially after eating.
When I was pregnant, I went to full-term. I had her naturally…yes, vaginally. No
complications, so I’m very confused as to what could be going on. I went to all my
prenatal appointments. They did tell me they saw something with her heart on the
ultrasound, and they kept having me go for more ultrasounds. I really don’t know what it
was. I guess it did sound serious. She was 6 pounds 10 ounces. She did get her hepatitis B
shot before we left the hospital. The doctors did their testing after she was born, and they
gave me a score like an 8 and then a 9. They did tell me we would need to see a heart
doctor, and I am scheduled for that. I did take her to the pediatrician a week after she was
born, but I didn’t really like that doctor. The doctor didn’t seem friendly to me. They tried
to explain this condition with her, but I really didn’t understand. They didn’t diagnose
her with anything except whatever is going on with her heart. She hasn’t had any
surgeries. She’s not allergic to anything at this point. I don’t give her anything but
formula and some of the infant vitamin drops. The doctor told me to give her those. She
sleeps most of the day. I feed her every 2 hours during the day. Could this be something
I’m doing? I don’t want to be hurting my baby. My medical history? Like I said before I
was told I have asthma when I was a kid. I haven’t taken any medication for a very long
 time. I don’t drink. I don’t smoke. Her father does though. He smokes about a pack a day
for about 4 years. He’ll have a drink after work sometimes. He’s a mechanic. He’s been
working there for about a year. I’m a supervisor at a hotel. I’m 26, and my fiancé is 25.
My fiancé is in a tech school for auto mechanic. I’ve been taking classes and hope to get a
BSN. I did drink coffee during pregnancy. Just a cup every now and then. Do you think
that’s what is causing this? I wish I hadn’t done that now. We have no family history of
diabetes or high blood pressure or high cholesterol or heart disease or any stroke on his
side or my side. We’re both relatively healthy. I like to run and have been going jogging
with the baby to stay active. My family’s around; our families are very close. They help us
out. My grandmother is around to help with cooking and cleaning and babysitting when I
need her. There’s stress, but it’s just like because new baby and a new house and finances
are a little tight right now. But we’re doing the best that we can. I just need somebody to
help my baby.”

Fall 2024- Vivien Thomas

Review of Systems

• Constitutional
MoB denies chills, fever, recent head trauma, recent changes in appetite, night sweats. MoB states
uncertain of current weight changes but weight gain was noted from birth to first doctor’s visit.

• Cardiovascular
See HPI; MoB states takes long time to feed; also falls asleep with feedings; no edema. MoB states
diaphoresis with feedings.

• Respiratory
See HPI. MoB states no wheezing, cough.

• Gastrointestinal
MoB states normal bowel movements reported; brownish to yellowish stools, no abdominal
distension, occasional spitting up after feeds, no vomiting.

• Genital
MoB denies vaginal discharge, erythema, or lesions.

• Urinary
MoB reports fewer wet diapers (3-4/day from 6-7/day) and possibly oliguria (with less heaviness to
diapers); no hematuria

• Musculoskeletal
MoB reports moving all extremities equally, no swelling, no tenderness, no erythema.
• Skin
MoB states blue-gray flat patches and nevi on back and buttocks

• Neuro
MoB denies sleep problems, tremors, weakness, seizures, or paralysis.

• Psych
MoB admits irritability during feeding.
Fall 2024- Vivien Thomas

Objective
Vital Signs: Temperature: 99.0 oF (rectally) Height: 20 inches
Pulse: 168 bpm Weight: 7 lbs 4 oz
Respirations: 62 rpm

Blood Pressure: 76/44 mmHg (left arm)

80/42 (right arm)
72/46 (left leg)
74/40 (right leg)
Pulse Ox: 86% Room air

General Appearance: The patient is a 6-week-old female who appears responsive. She is in
mild physical distress.

HEENT:
Head: normocephalic, anterior and posterior fontanelle open and flat, sutures not
overlapping, symmetric head,
Eyes: normal shape and placement, conjunctiva clear; pupils equal and reactive to light;
bilateral red reflex present and equal; external ocular muscles grossly intact and
aligned, unable to visualize fundus and retina
Ears: normally placed, normal shape and contour, no ear pits, or tags; external auditory
canals patent and clear of debris; tympanic membranes are pearly gray and
display normal cone of light and normal bony landmarks; no tympanic
membrane inflammation or perforation
Nose: no swelling of nasal turbinates; no nasal discharge
Mouth/Throat: moist mucous membranes, no cleft lip nor palate, no pharyngeal
inflammation, or exudates; no supernumerary teeth; no Epstein pearls, uvula
midline; tongue midline and not enlarged; no tongue-tie noted; no thyroglossal
duct cyst; no oral lesions or leukoplakia.

Face: symmetrical and no obvious deformities

Neck: supple without masses; trachea is midline and movable; no lymphadenopathy;

thyroid is not palpable

Heart: tachycardic ~160 bpm, harsh 4/6 crescendo-decrescendo holosystolic murmur

present throughout chest louder over left upper sternal border and radiating to
back; no gallops, no rubs

Lungs: good aeration bilaterally; no wheezes, no rhonchi, or rales

Fall 2024- Vivien Thomas

Chest: no deformity, clavicles intact, mild costal and subcostal retractions

Breast: no swelling nor discharge

Abdomen: bowel sounds present; mild distention, soft with no obvious tenderness to
palpation; umbilical cord, 1 vein and 2 arteries, without abnormalities and healing
well; no masses, no splenomegaly, liver palpated 1 cm below costal margin,
femoral pulse present with no femoral brachial delay.

Genital: normal female, no swelling, small amount milky white discharge, or adhesions
noted, no ambiguous genitalia.

Osteopathic
Structural cervical, thoracic, and lumbar curvatures are normal; no scoliosis noted.
Exam: range of motion is unrestricted in cervical, thoracic, and lumbar areas

Extremities: no clubbing; no edema; no restriction of range of motion; full range of motion of

hips, negative Ortolani and Barlow maneuvers, symmetric gluteal and leg
creases, no deformities.

Skin: Dermal melanocytosis noted to back and buttocks; lanugo noted diffusely over
body; small nevus simplex noted to medial aspect upper eyelid; dusky skin color
but not blue, no current central or acrocyanosis, no jaundice

Neurological: tone normal, strong grasp; neonatal reflexes present, appropriate startle to loud
noises; Moro reflex symmetric, rooting reflex intact, stepping reflex present,
strong sucking reflex; occasional cries however calms when picked up.
 Fall 2024- Vivien Thomas

Discussion Questions

1. Construct a differential diagnostic list of clinical conditions that can present as a cyanotic infant.

2. List Baby Vivien’s symptoms and identify the significant abnormalities in her history and physical exam.
Explain the underlying pathological processes (molecular, cellular, tissue and organ levels) of each. Include the
following:
• Cyanosis
• Murmur
• Tet spells

3. Using information from the history and physical examination to justify your choices, identify those
clinical conditions in your differential diagnostic list that are supported by this patient's clinical presentation,
and discard those that lack substantial support. Explain your choices.

4. List the diagnostic tests you would order for Baby Vivien. Explain the reasons for your choices.

5. Interpret the results of the diagnostic tests provided by the facilitator and explain any abnormal values in
terms of underlying molecular, cellular, or anatomical pathologies.

6. Refine your differential diagnosis list based on the lab values, explaining your choices.

7. List additional diagnostic tests that are needed to further refine your diagnosis, explaining the rationale
behind each.

8. Discuss the process of cardiac embryogenesis and how it contributed to Baby Vivien’s presentation.

9. Compare and contrast the prenatal vs postnatal circulation of Baby Vivien including the important
structures and changes that occur after birth.

10. Discuss the 4 elements of Baby Vivien’s disease and how the structural issues impact cardio-pulmonary-
systemic blood flow, pressures, and oxygen saturation. Explain how these structural problems and the ensuing
circulation cause the clinical findings of tet spells (episodic cyanosis), failure to thrive, clubbing, irritability, heart
failure.
 Fall 2024- Vivien Thomas

11. Discuss the hemodynamics of Eisenmenger syndrome.

12. Discuss external factors {medicine, infectious disease agents, environmental) that have been associated
with congenital heart disease.

13. Discuss the embryology, hemodynamics, natural history or presentation and management options for the
following congenital heart defects.
• Ventricular septal defect (VSD)
• Atrial septal defect (ASD)
• Patent ductus arteriosus
• Pulmonary stenosis
• Bicuspid Aortic valves (BAVs)
• Atrioventricular Septal Defects
• Left Ventricular Outflow Tract Obstruction
• Coarctation of the Aorta
• Complete Transposition of the Great Arteries
• Ebstein Anomaly of the Tricuspid Valve
• Tetralogy of Fallot

14. Discuss treatment options- medical and surgical regarding Baby Vivien’s pathology

15. Discuss psychosocial aspects of patients that are diagnosed with congenital heart defects
including preventative measures, possible complications, and continued health care needs.

BONUS QUESTION

16. Discuss the appropriate timeline of pediatric care after delivery, include visits, immunizations, and
development milestones.

[END OF STUDENT VERSION]

Fall 2024-Vivien Thomas

Case Writer
Thomas Chan, D.O.

Case Collaborators
Gregory Saggio, D.O.
Sharon Koehler, D.O., F.A.C.S.

Editors
Jude Cope, D.O.
Peter Dane, D.O.
Christine Hartford, D.O.
Adrienne Loftis, M.S., D.O.
Mitzi Scotten, M.D.
Hillary Sismondo, M.D.
Jennifer Xie, Ph.D.
Thomas Chan, D.O.
Maria A. Pino, Ph.D, M.S., R.ph.