Clinical findings in a 3 month old infant with acyanotic congenital heart disease- VSD and PDA

1. Acyanotic Congenital Heart
Disease Ventricular Septal Defect
(VSD) and Patent Ductus
Arteriosus (PDA)
Lavina Belayutham

2. Systemic
Examination

3. Cardiovascular System Examination
Inspection
• Shape of the chest is normal and is bilaterally
symmetrical.
• Trachea appears central.
• No visible precordial bulge.
• Apex beat is visible at the left 5th
intercostal
space, lateral to the midclavicular line.
• Suprasternal pulsations seen.
• No dilated veins, scars or sinuses.

4. Palpation
• Trachea is confirmed to be central.
• Apical impulse confirmed to be in the left 5th
intercostal space, lateral to the midclavicular
line.
• Hyperdynamic apex beat
• Palpable thrill felt at second left intercostal
space (PDA)
• Palpable thrill felt along the left parasternal
region (VSD)
• Parasternal heave is present

5. Percussion
Not performed

6. Auscultation
Area Findings
Aortic S1S2 heard
Pulmonary S1S2 heard
Grade IV continuous murmur best heard
with the diaphragm of the stethoscope
Mitral S1S2 heard
Tricuspid S1S2 heard
High pitched, pansystolic murmur of
grade IV best heard with the diaphragm
of the stethoscope in the left parasternal
region especially in the 3rd
and 4th
intercostal space
Infraclavicular S1S2 heard
Grade IV continuous murmur best heard
with the diaphragm of the stethoscope
Left second intercostal space S1S2
Grade IV continuous murmur best heard
with the diaphragm of the stethoscope

7. Respiratory system examination
Inspection
-Flaring of ala nasi is present
-Trachea appears to be central
-Chest movements are bilaterally symmetrical
-Chest indrawing present
-Subcostal recession present
-No dilated veins, scars, sinuses

8. Palpation
- The inspectory findings are confirmed
-Trachea is confirmed to be central
-Chest movements are equal on both sides
-Chest circumference : 36cm
Percussion
-Resonant note heard in all the lung areas
-Cardiac dullness present at left 5th intercostal space,
lateral to midclavicular line
Auscultation
-Normal vesicular breath sounds heard
-No added sound

9. Per abdomen Examination
- Soft, non tender
- No organomegaly
- No free fluid in the abdomen
Central Nervous System Examination
-No neurological deficit

10. Per abdomen Examination
- Soft, non tender
- No organomegaly
- No free fluid in the abdomen
Central Nervous System Examination
-No neurological deficit