Paediatric Cardiology new patient

Paediatric Cardiology new patient Indication for referral: Dr. Emily Carter referred 8-year-old patient, Lily Jones, due to a heart murmur detected during a routine check-up. The referring physician expressed concerns about potential congenital heart disease, given the family history of cardiac issues. The patient is otherwise asymptomatic. History: Chief Complaint: Heart murmur. History of Present Illness: The heart murmur was first noted by Dr. Carter during a well-child visit. The patient denies any chest pain, shortness of breath, or syncope. No history of cyanosis or feeding difficulties. The patient's activity level is normal for her age. Past Medical History: Unremarkable. Surgical History: None. Family History: Father has a history of premature coronary artery disease. Maternal grandfather had a history of mitral valve prolapse. Social History: Lily is a happy and active child, living with both parents and a younger sibling. No smoking or alcohol use. Review of Systems: Negative for chest pain, palpitations, dizziness, or easy fatigability. Examination: Vitals: Blood pressure 110/70 mmHg, heart rate 88 bpm, respiratory rate 20 breaths/min, SpO2 99% on room air. General: Well-appearing, alert, and cooperative child. Cardiac: Grade II/VI systolic murmur heard best at the left sternal border. Regular rhythm. No clicks or gallops. Peripheral pulses are 2+ and equal bilaterally. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, no hepatosplenomegaly. Echocardiography: Echocardiogram performed on 1 November 2024 revealed a small atrial septal defect (ASD) measuring 5mm with a left-to-right shunt. Ventricular function is normal. No other structural abnormalities were identified. Pulmonary artery pressure is within normal limits. 12 Lead ECG: ECG showed normal sinus rhythm with a rate of 88 bpm. Normal axis. PR interval 0.14 seconds, QRS duration 0.08 seconds, and QT interval 0.38 seconds. No ST-T wave abnormalities were noted. Impression: Small atrial septal defect (ASD). The patient is currently asymptomatic. No evidence of pulmonary hypertension. Outcome: Plan: Schedule follow-up echocardiogram in 6 months to monitor the ASD. Discussed the findings with the parents, and provided education on the condition. Advised the patient to maintain a normal activity level. No medication is required at this time. Referral to cardiology clinic for further management and monitoring. The patient and parents were provided with educational materials regarding ASD.