14y F VSD

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A 14 YEAR OLD FEMALE CAME TO THE OPD WITH THE COMPLAINTS OF CHEST PAIN SINCE 1 MONTH SOB SINCE 1 MONTH, PATIENT WAS APPRENTLY ASSYMPTOMATIC 1 MONTH BACK THEN DEVELOPED CHEST PAIN INSIDIOUS IN ONSET INTERMITTENT PRICKING TYPE AGGREVATED ON EXCERTION

SOB GRADE II INSIDIOUS ONSET

NO H/O OF PALPITATIONS AND SWEATING

NO H/O OF FEVER COLD COUGH

NO H/O BURNING MICTURATION

THE PT WAS STARTED ON CONSERVATIVE MANAGEMENT (TMVT PO OD)

GENERAL EXAMINATION

THE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

MODERATELY BUILT AND NOURISHED

SIGNS OF PALLOR

NO ICTERUS, CYANOSIS, CLUBBING EDEMA

VITALS

TEMP AFEBRILE

PR: 63 BPM

RR 16 CPM

8P 110/70 MM HG

SPO2: 95% RA

GRBS 114 MG/DL

CVS S1, S2 HEARS,PAN SYSTOLIC MURMUR HEARD AT THE FOLLOWING 1,2,3,4,5

THE INTENSITY OF MURMUR INCREASED FROM 1 TO 5

RS: BAE+ NVBS +

TRACHEA: CENTRAL

NO DYSPNOEA AND WHEEZE

NO RHONCHI

ABDOMEN: TENDER, SOFT, DISTENDED, UMBLICAL HERNIA PRESENT

LIVER AND SPLEEN NOT PALPABLE

BOWEL SOUNDS NOT HEARD

CNS:

LEVEL OF CONSCIOUSNESS: CONSCIOUS, ALERT

SPEECH NORMAL

NECK STIFFNESS ABSENT

KERNINGS SIGN ABSENT

CRANIAL NERVES: NORMAL

MOTOR SYSTEM: NORMAL

SENSORY SYSTEM: NORMAL

GCS: 15/15 E4V5M6

CARDIOLOGY REFERAL DONE ON 2/1/24

Peri membraneous vsd with sob

No h/o bluish discoloration of skin

Cvs: pan systolic murmur present

2d echo findings 

Moderate, peri membrane vsd

ADVICED

SURGICAL CLOSURE

TAB DYTOR 5 MG PO SOS

XRAY CHEST PA VIEW

SNOW MAN APPEARANCE OF HEART

2D ECHO

Treatment

TAB DYTOR 5 MG PO SOS

ELECTRONIC DISCHARGE