Name :PUJAPPA Age :14yrs Sex :Male Address:Marenali Bagnur post ,yelanka ,Bangalore North. Informant :Father ,Mother & self(reliable) DOA:17-03-05

No h/o cough, fever, chest indrawing No h/o palpitation,edema of feet,decrease urine output. No h/o headache,vomiting,convulsions, weakness of limbs.

Past h/o:h/o URI 2-3 times /year No h/o suggestive of ALRI No h/o admission to hospital Family h/o:non consanguineous marriage.

No h/o CHD No h/o CHD

Birth h/o:unbooked & unimmunised 1—no h/o drug intake,fever with rash 2--- no h/o suggestive PIH,DM home delivery conducted by untrained dai. BCIAB avg wt baby.prelacteal feeds sugar water 2-3spoons .started breast feeding 2hr after birth till 5months. No h/o intermittent feeds No h/o sweating over forehead during feeding

No h/o fever ,cough, chest indrawing. Immunisation h/o: Unimmunised(unawareness) Development h/o:appropriate for age.

NUTRITION H/o Required Getting deficit 2400 Kcal 1400 58% 70 gms 48 65% Required Getting deficit 2400 Kcal 1400 58% 70 gms 48 65%   NUTRITION H/o

Socioeconomic h/o:Father 1st std ,Mother illiterate --coolie Rs 500/month. 1room 1kitchen kerosene stove cooking out door sanitation. low socioeconomic status

summary 14yr old male boy pujappa 5th child of non consanguineous marriage presented with h/o breathlessness on exertion with squatting episodes since age of 3yrs. h/o cyanosis h/o not gaining wt. no h/o repeated ALRI/CCF

CCHD with decrease pulmonary blood flow TOF TGV with VSD with PS DORV with PS Single ventricle with PS

ANTHROPOMETRY expected Wt 24kg (5th centile) 35kg Ht 142cm(25th centile)150cm HC 51cm CC 57cm Wt age Ht age 13 yrs weight more affected Wt for ht 77.4 than height US/LS 0.9

VITALS PR -72/min regular, good volume,all peripheral pulses well felt,no R-R,no R-F delay BP- 100/68mmhg—UL, 110/70 –LL. RR-18/min Temp –Afebrile JVP--N

HEAD TO TOE EXAMINATION Head –N Eyes –conjunctival xerosis,conjunctival suffusion Ears –N Nose –N Neck –no lymphadenopathy Mouth – lips & tongue –cyanosis ,no caries Hands –nails –cyanosis,clubbing –grade 3 Feet –toes-- cyanosis,clubbing –grade 3,no pedal edema SMR –stage 2

Thorax & abdomen –Branding marks + Skin –N Bones & joints –N Spine– N No facial dysmorphism No extracardiac markers No features of infective endocarditis.

SYSTEMIC EXAMINATION PR-72/min BP-100/68-UL,110/70-LL JVP-N Inspection :Apical impulse seen in 4th ICS medial to MCL. No precordial bulge No other visible pulsations.

Palpation :Apical impulse seen in 4th ICS 0.5cm medial to MCL,Normal. Thrill left 2,3,4 ICS along sternal border. Parasternal heave grade 1 no epigastric pulsation, no palpable P2 Percusion :left border corresponds to apex.

Auscultation :heart sounds S1 S2 heard ejection systolic murmur of grade 4 heard best in left upper sternal border with diaphragm ,during inspiration,with sitting posture. MA:S1S2+ same ejection systolic murmur + PA : S1S2+, single S2,well heard , same ejection systolic murmur . TA: S1S2+ AA:S1S2+

RS :Trachea central B/L symmetrical chest movement+ B/L air entry NVBS+ P/A:Soft no organomegaly ,BS+ CNS:No focal neurological deficits.

Impression :CCHD with decreased pul blood flow in sinus rhythm, with out failure, with no evidence of IE. TOF DORV with PS TGV with VSD with PS

Investigations Hb :16.8 gm/dl PCV:58.8% TC-8,600cells/cumm DC N-71% L-22% E-4% M-3% RBC 7.55million/cumm Platelet :2.23lac PBS:normocytic normochromic

ECG:HR-72/min regular rhythm PR interval 0.16sec QT interval 0.32 sec Right axis deviation (+120) RVH –Tall R wave in V1 &deep S wave in V6

Chest X-ray: ECHO: