Develop a pediatric case on Atrial septal defect on a 20 months old chlid with the chief complaints of cough since 3days, fever since 1day , shortness of breath for 6 hours accordingly provided case sheet format
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PEDIATRIC CLINICAL CASE SHEET
Standard OSCE / Clinical Case Format
PATIENT IDENTIFICATION
| Field | Details |
|---|---|
| Name | Baby Arjun Kumar (fictitious) |
| Age | 20 months |
| Sex | Male |
| Weight | 8.5 kg (below 3rd centile for age) |
| Height | 78 cm (below 5th centile for age) |
| Date of Admission | 14-July-2026 |
| Ward / Unit | Pediatric Medical Ward, Bed 4 |
| Informant | Mother (reliable) |
| MRD No. | XXXX |
CHIEF COMPLAINTS
| S. No. | Complaint | Duration |
|---|---|---|
| 1. | Cough | 3 days |
| 2. | Fever | 1 day |
| 3. | Shortness of breath | 6 hours |
HISTORY OF PRESENT ILLNESS
Baby Arjun, a 20-month-old male child, was apparently well until 3 days ago when he developed a cough - initially dry, progressing to productive with whitish sputum. The cough is continuous, non-paroxysmal, and aggravated on lying down. There is no history of barking character or whooping. Fever started 1 day ago, low grade initially (recorded at home as 99.5-100.4°F), becoming high grade (101.8°F) at presentation. The fever is continuous, not associated with chills or rigors. Shortness of breath started 6 hours before admission, progressively worsening, associated with fast breathing and visible use of neck muscles during breathing. The child was unable to feed well since the onset of dyspnea.
The child has a documented history of a cardiac murmur noted incidentally at 4 months of age during a routine well-child visit. Echocardiography done at 6 months confirmed a secundum atrial septal defect (ASD) of 8 mm with significant left-to-right shunt. The child was under cardiology follow-up but no intervention had been performed.
The mother reports 4 similar episodes of lower respiratory tract infections (LRTIs) in the past 10 months, each requiring hospitalization, consistent with recurrent pulmonary infections in a child with a large left-to-right shunt. The child tires easily during feeding (takes >30 minutes per feed), frequently stops to breathe, and sweats profusely during feeds.
HISTORY OF PAST ILLNESS
- 4 previous hospitalizations for pneumonia / bronchiolitis (at 10, 13, 16, and 18 months of age)
- No surgeries or cardiac interventions to date
- No known drug allergies
- No history of rheumatic fever or tuberculosis
BIRTH HISTORY
| Parameter | Detail |
|---|---|
| Type of delivery | Full-term normal vaginal delivery |
| Birth weight | 2.8 kg |
| Birth cry | Immediate |
| NICU admission | No |
| Antenatal history | No maternal illness, no teratogenic drug exposure; rubella serology not done |
| Perinatal complications | None |
DEVELOPMENTAL HISTORY
| Milestone | Age of Attainment | Expected Age | Status |
|---|---|---|---|
| Social smile | 2 months | 2 months | Normal |
| Head holding | 4 months | 3-4 months | Slightly delayed |
| Sitting with support | 8 months | 6 months | Delayed |
| Sitting without support | 10 months | 8 months | Delayed |
| Standing with support | 14 months | 9 months | Delayed |
| Walking independently | 18 months | 12-13 months | Delayed |
| Meaningful words (2-3) | 15 months | 12 months | Mildly delayed |
| Pincer grasp | 12 months | 9-10 months | Mildly delayed |
Impression: Global developmental delay, predominantly motor - likely related to chronic cardiopulmonary compromise and poor weight gain.
DIETARY HISTORY
- Breastfed exclusively for 5 months; supplementary feeds started at 5 months
- Currently on semi-solid diet + cow's milk
- Poor appetite, tires during feeds, takes small frequent feeds
- No diet diversification; micronutrient supplementation not consistent
IMMUNIZATION HISTORY
| Vaccine | Status |
|---|---|
| BCG | Given at birth |
| OPV 0, 1, 2, 3 | Complete |
| Pentavalent 1, 2, 3 | Complete |
| IPV | Given |
| Rotavirus | Given |
| PCV | 2 doses given (3rd pending) |
| Measles/MR | Given at 9 months |
| Booster doses (DPT/OPV) | Not yet due |
Immunization status: Complete for age as per National Immunization Schedule (India).
FAMILY HISTORY
- Father: 28 years, healthy
- Mother: 25 years, healthy, one prior normal pregnancy
- No family history of congenital heart disease or other hereditary conditions
- No consanguinity
SOCIOECONOMIC HISTORY
- Lower-middle socioeconomic class (Kuppuswamy scale)
- Nuclear family, lives in a 2-room house
- Father is a daily wage laborer
- Immunization from government health center
- No tobacco or biomass smoke exposure in the household
SYSTEMIC REVIEW
- Respiratory: Recurrent LRTIs (as above); no history of wheeze in between episodes
- CVS: Known ASD; no cyanosis at rest; no syncope; no palpitations; feeding difficulties as described
- GI: Anorexia; no vomiting, diarrhea, or abdominal distension; no jaundice
- CNS: No seizures; developmental delay as above
- Renal: Normal urine output; no puffiness of face
- Musculoskeletal: No joint swelling or pain
GENERAL PHYSICAL EXAMINATION
| Parameter | Finding |
|---|---|
| General appearance | Irritable, not in severe respiratory distress at rest; sitting propped up |
| Anthropometry | Weight 8.5 kg (< 3rd centile); Height 78 cm (< 5th centile) - Grade II Protein Energy Malnutrition (IAP classification) |
| Temperature | 101.8°F (38.8°C) |
| Heart Rate | 148 beats/min, regular |
| Respiratory Rate | 58 breaths/min (tachypnea) |
| SpO2 | 91% on room air (improved to 96% on 2 L/min O2 via nasal prongs) |
| Blood Pressure | 88/54 mmHg (upper limb, right) |
| Capillary Refill Time | 3 seconds |
| Pallor | Mild pallor present |
| Icterus | Absent |
| Cyanosis | No cyanosis at rest; no peripheral or central cyanosis; no clubbing |
| Lymphadenopathy | No significant cervical lymphadenopathy |
| Edema | Absent |
| Skin | No rashes; mild subcutaneous fat loss |
SYSTEMIC EXAMINATION
A. Respiratory System
| Finding | Detail |
|---|---|
| Inspection | Tachypnea (RR 58/min); subcostal and intercostal retractions present; nasal flaring; no chest deformity |
| Chest shape | Slight precordial bulge on left (consistent with cardiomegaly) |
| Palpation | Trachea central; tactile fremitus increased on right infra-axillary and right infrascapular region |
| Percussion | Dull note in right lower zone posteriorly |
| Auscultation | Decreased breath sounds with coarse crepitations in right lower lobe; fine crepitations bilateral; no wheeze |
Impression: Right lower lobe consolidation (pneumonia) superimposed on a background of pulmonary plethora from left-to-right shunt.
B. Cardiovascular System
| Finding | Detail |
|---|---|
| Inspection | Precordial bulge present; visible cardiac impulse at left 4th intercostal space |
| Palpation | Apex beat at left 5th intercostal space, lateral to midclavicular line - displaced (left ventricular enlargement); left parasternal heave present (RV volume overload); no thrill |
| Percussion | Cardiac dullness slightly enlarged to left |
| Auscultation | |
| - S1 | Normal |
| - S2 | Wide and fixed splitting of S2 - hallmark of ASD; P2 slightly accentuated |
| - Murmur | Grade 2/6 ejection systolic murmur heard best at left upper sternal border (pulmonary area) - due to increased flow across pulmonary valve (relative pulmonary stenosis from large left-to-right shunt) |
| - Additional | Mid-diastolic murmur at tricuspid area (Carey Coombs equivalent - increased tricuspid flow in large ASD) |
| Femoral pulses | Normal volume bilaterally |
| JVP | Not assessable in infant; anterior fontanelle: flat |
Cardiovascular impression: Features consistent with large secundum ASD with significant left-to-right shunt and right ventricular volume overload.
C. Abdomen
| Finding | Detail |
|---|---|
| Inspection | Slightly distended |
| Palpation | Liver palpable 3 cm below right costal margin, firm, non-tender - hepatomegaly (early right heart failure / increased venous return) |
| Spleen | Not palpable |
| Kidneys | Not palpable |
| Percussion | Shifting dullness absent |
| Auscultation | Bowel sounds present |
D. Central Nervous System
- Conscious, irritable
- Anterior fontanelle flat and normotensive
- Tone: normal for age
- Reflexes: normal
- No meningeal signs
INVESTIGATIONS
Bedside / Immediate
| Investigation | Result | Interpretation |
|---|---|---|
| SpO2 (room air) | 91% | Low - hypoxia due to pneumonia |
| Blood glucose (rapid) | 80 mg/dL | Normal |
| CRT | 3 seconds | Borderline prolonged |
Haematology
| Test | Result | Normal (20 months) | Interpretation |
|---|---|---|---|
| Hb | 9.2 g/dL | 11.0-14.0 g/dL | Mild anemia |
| TLC | 17,400 cells/mm³ | 6,000-17,000 | Mild leukocytosis |
| Neutrophils | 74% | 25-70% | Neutrophilia |
| Lymphocytes | 22% | - | - |
| Platelets | 3.4 lakhs/mm³ | 1.5-4.0 lakhs | Normal |
| ESR | 38 mm/hr | < 20 | Elevated |
| CRP | 28 mg/L | < 6 mg/L | Elevated (acute infection) |
Biochemistry
| Test | Result | Interpretation |
|---|---|---|
| Serum Na | 134 mEq/L | Mild hyponatremia |
| Serum K | 3.8 mEq/L | Normal |
| Serum Ca | 8.6 mg/dL | Normal |
| Blood urea | 28 mg/dL | Normal |
| Serum creatinine | 0.4 mg/dL | Normal |
| Serum albumin | 2.9 g/dL | Low (malnutrition) |
| LFT | Mildly elevated ALT 38 U/L | Hepatic congestion |
| Blood culture | Sent; pending | - |
Radiology
Chest X-Ray (PA view):
- Cardiomegaly: Cardiothoracic ratio = 0.58 (> 0.55 abnormal in infants)
- Plethoric lung fields (increased pulmonary vascular markings bilaterally)
- Right lower lobe consolidation (homogenous opacity with air bronchograms)
- Prominent pulmonary artery segment
- No pleural effusion
ECG
| Feature | Finding |
|---|---|
| Rate | 148/min |
| Rhythm | Sinus tachycardia |
| Axis | Right axis deviation (+110°) |
| P wave | Normal |
| QRS | rSR' pattern (incomplete RBBB) in V1 - classic for ASD |
| ST-T changes | None |
ECG impression: Sinus tachycardia with right axis deviation and incomplete right bundle branch block - consistent with ASD-related right ventricular volume overload.
Echocardiography (previous report at 6 months; repeat ordered)
| Finding | Detail |
|---|---|
| ASD type | Secundum |
| Defect size | 8 mm (significant) |
| Shunt direction | Left-to-right |
| Qp:Qs ratio | 2.4:1 (at 6 months) |
| RV | Dilated |
| PA pressure | Mildly elevated (35 mmHg estimated) |
| LV | Normal function, EF 62% |
| Mitral valve | Normal |
| No other defects | - |
Current echo ordered to reassess shunt, RV function, and PA pressure in context of clinical deterioration.
DIAGNOSIS
Working Diagnosis (Primary)
Community-Acquired Pneumonia (right lower lobe) with respiratory failure
in a known case of Secundum Atrial Septal Defect (large, 8 mm) with significant left-to-right shunt
Background Diagnoses
- Secundum ASD - large, unrepaired
- Right ventricular volume overload with mild pulmonary arterial hypertension
- Recurrent lower respiratory tract infections (4th episode in 10 months) - related to pulmonary plethora from large shunt
- Grade II Protein Energy Malnutrition - related to high metabolic demand and feeding difficulties
- Global developmental delay - secondary to chronic cardiopulmonary compromise
Differential Diagnosis
| Condition | For | Against |
|---|---|---|
| VSD with LRTI | Systolic murmur, recurrent LRTI, cardiomegaly | Murmur at LUSB, fixed split S2, rSR' pattern - all favor ASD over VSD |
| PDA with LRTI | Pulmonary plethora, recurrent LRTI | No continuous murmur, no bounding pulses |
| Simple community-acquired pneumonia | Fever, cough, consolidation | Background cardiac disease, recurrent pattern, cardiomegaly |
| Heart failure (primary) | Hepatomegaly, tachycardia, failure to thrive | Triggered by current infection, underlying structural defect |
MANAGEMENT PLAN
Immediate Stabilization (A-B-C-D-E)
- Airway: Clear, patent - maintain positioning (semi-recumbent)
- Breathing: O2 supplementation 2 L/min via nasal prongs; target SpO2 > 95%; monitor for worsening respiratory failure (may need escalation to high-flow oxygen or CPAP)
- Circulation: IV access established; fluid restrict at 80% maintenance (due to cardiac compromise)
- IV fluids: DNS + KCl @75 mL/hr (80% maintenance for 8.5 kg child); monitor for fluid overload
- IV antibiotics:
- Injection Ampicillin-Sulbactam 200 mg/kg/day IV q6h (first-line CAP with cardiac background)
- Injection Azithromycin 10 mg/kg OD IV (atypical coverage)
- Review culture sensitivity at 48-72 hours
- Antipyretics: Syrup Paracetamol 15 mg/kg/dose q6h PRN (oral/nasogastric)
- Diuretics: Injection Furosemide 1 mg/kg IV stat, then 0.5 mg/kg q12h (to reduce pulmonary congestion; monitor serum electrolytes)
- Positioning: Head-end elevated 30°; prone positioning avoided acutely
- NBM / NG feeds: NPO during acute distress; start NG feeds once RR < 50/min
Cardiac-Specific Management
- Digoxin: Syrup Digoxin 0.01 mg/kg/day (5 mcg/kg/day) OD - for rate control and mild inotropic support (if signs of CHF persist after diuresis); check serum levels
- Repeat Echocardiography: Reassess shunt fraction, RV function, PA pressures after acute illness
- Pediatric Cardiology referral: For definitive management planning - timing of ASD closure
- ASD closure indications in this child:
- Recurrent LRTIs (4 episodes in 10 months)
- Failure to thrive / PEM Grade II
- Large defect (8 mm) with Qp:Qs > 2:1
- Elective device closure (Amplatzer Septal Occluder) or surgical closure advised after resolution of acute illness - typically recommended before school age, but brought forward here due to recurrent complications
Supportive Management
| Intervention | Detail |
|---|---|
| Nutritional rehabilitation | High-calorie feeds (100-150 kcal/kg/day) via NG tube during acute phase; dietitian consultation |
| Vitamin and micronutrients | Iron supplementation (3 mg/kg/day elemental iron) for anemia; Zinc 10 mg OD x 14 days (pneumonia) |
| Physiotherapy | Chest physiotherapy after acute fever settles (postural drainage, percussion) |
| Nebulization | 3% hypertonic saline / salbutamol 0.15 mg/kg q4h if significant wheeze or atelectasis |
| Developmental assessment | Formal neurodevelopmental assessment after discharge; early intervention program |
Monitoring
| Parameter | Frequency |
|---|---|
| SpO2, HR, RR | Continuous monitoring |
| Temperature | 4-hourly |
| Weight | Daily (assess fluid status) |
| Urine output | Hourly (catheter if needed) |
| Serum electrolytes | 12-hourly while on diuretics |
| Blood culture sensitivity | At 48 hours |
| ABG | If SpO2 < 90% despite O2 therapy |
| Chest X-Ray | Repeat at 48-72 hours |
| Echo | After recovery from acute illness |
Criteria for ICU Transfer
- SpO2 < 88% despite high-flow O2
- RR > 70/min with worsening retractions
- Altered sensorium / apnea
- Shock (CRT > 4 sec, BP falling)
- Need for mechanical ventilation
PROGNOSIS
| Aspect | Comment |
|---|---|
| Immediate (acute pneumonia) | Favorable with appropriate antibiotic and supportive therapy |
| Medium-term (cardiac) | Good if ASD closure performed soon; risk of progressive pulmonary hypertension, Eisenmenger syndrome if left unrepaired beyond childhood |
| Long-term (post-closure) | Near-normal life expectancy; pulmonary hypertension partially reversible at this stage |
| Nutritional / developmental | Significant improvement expected post-cardiac repair with adequate nutritional support |
COUNSELLING POINTS (For Parents)
- The child has a hole between the upper chambers of the heart (ASD) that is causing extra blood flow to the lungs - this weakens the lungs and causes repeated chest infections.
- The current infection is being treated with IV antibiotics and oxygen.
- The hole in the heart needs to be closed by a minimally invasive procedure (catheter-based device closure) once this infection is treated - this will prevent future pneumonias and improve the child's growth.
- Regular follow-up with the pediatric cardiologist is essential.
- Ensure all vaccines are up to date, including Influenza and PCV booster.
- Nutritional counselling: high-calorie small frequent feeds; follow up with a dietitian.
- Signs of worsening to watch for at home: fast breathing, bluish discoloration of lips, poor feeding, excessive sweating - report immediately.
SIGNATURE / DESIGNATION
Attending Pediatrician: Dr. _______________________
Resident / Intern: Dr. _______________________
Date: 14-July-2026 | Time: 19:47 hrs
References: Harrison's Principles of Internal Medicine 22E (2025) - ASD pathophysiology and clinical features; Sabiston Textbook of Surgery - ASD surgical management; The Harriet Lane Handbook 23rd ed. - Pediatric cardiac murmur classification and management; Nelson Textbook of Pediatrics - standard pediatric assessment framework.
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