Review Question - QID 109384

A 5-year-old girl presents to the pediatrician for a well visit. She recently entered kindergarten and her teacher expressed concern that the patient is not meeting developmental milestones. She struggles to name colors and has not expressed any interest in learning to read. The patient’s parents have also noticed that the patient is not completing tasks that her older siblings were doing by this age such as dressing or going to the bathroom by herself. The patient rolled over at 9 months, sat without support at 12 months, and walked at 20 months. The patient is very social and adults frequently comment on her friendly personality. The patient is in the 15th percentile for weight and 5th percentile for height. Her temperature is 98.4°F (36.9°C), blood pressure is 85/56 mmHg, pulse is 108/min, and respirations are 26/min. On physical exam, the patient has a broad forehead, flat nasal bridge, long philtrum, and a wide mouth. She has strabismus on a neurological exam and her cardiac exam is significant for a heart murmur. Laboratory testing is below:

Serum:
Na+: 145 mEq/L
K+: 3.9 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/
Urea nitrogen: 11 mg/dL
Glucose: 76 mg/dL
Creatinine: 0.9 mg/dL
Ca2+: 11.9 mg/dL

Which of the following cardiac abnormalities is associated with the patient's most likely condition?