Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of a heart murmur. History is significant for [asymptomatic/tachypnea with feeds/poor weight gain/diaphoresis during exertion]. No history of cyanotic spells. Parents report [normal/delayed] growth milestones.
Clinical Examination Findings
Cardiovascular: Precordial activity is [normal/hyperdynamic]. Auscultation reveals a [grade I-VI/VI] [harsh/holosystolic] murmur heard best at the [left lower sternal border]. [S1/S2] is [normal/split]. No palpable thrill. Peripheral pulses are [symmetrical/bounding]. Lungs: Clear to auscultation bilaterally. No hepatomegaly.
Treatment Protocol
Plan: 1. Echocardiogram to confirm VSD size, location, and hemodynamic significance. 2. Monitor weight gain and nutritional intake. 3. Consider [diuretics/ACE inhibitors] if signs of congestive heart failure are present. 4. Referral to Pediatric Cardiology for follow-up and potential surgical/device closure assessment.