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You refer this patient to your local pediatric cardiologist who confirms your diagnosis. However, when he recommends surgical repair to the mother she refuses. As far as she can tell, he appears normal other than being a little small. Also, the thought of surgery frightens her. After leaving his office, the mother fails to bring her child back in for follow-up, but presents to your ER 1 year later. Now the child shows signs of cyanosis and is tachypneic. CXR this time shows left atrial and ventricular enlargement as well as increased pulmonary vascularity. How do you explain the childs current condition?

  1. a) worsening left-to-right shunt
  2. b) closure of PDA
  3. c) right-sided pneumothorax
  4. d) right-to-left shunt
  5. e) Failure of foramen ovale to close
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