Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of PAH associated with congenital heart disease (CHD). Symptoms include [NYHA Class I/II/III/IV] dyspnea on exertion, fatigue, and occasional palpitations. No reported syncope, chest pain, or peripheral edema. Current CHD anatomy: [e.g., ASD/VSD/PDA/Complex]. Hemodynamics stable on current regimen of [Medication].
Clinical Examination Findings
Vitals: BP [X/X], HR [X], SpO2 [X%]. General: Alert, no acute distress. CV: Regular rate and rhythm, loud P2, holosystolic murmur at [Location], no S3/S4. Lungs: Clear to auscultation bilaterally. Extremities: No cyanosis, no clubbing, trace pedal edema [+/-]. JVP: [Elevated/Normal] cm H2O.
Treatment Protocol
Plan: Continue current PAH-targeted therapy: [Medication/Dose]. Monitor for side effects. Advise strict adherence to sodium-restricted diet. Follow-up with echocardiogram in [Timeframe] to assess RV function and estimated PASP. Repeat 6-minute walk test (6MWT) to evaluate functional capacity.