Heart Murmurs

Question 1

cardiac murmur is frequently recognized in healthy children

Answer 1

but it can also be the presenting feature in many forms of congenital heart disease,

including re-gurgitation or stenosis of heart valves or left-to-right shunt lesions at the atrial, ventricular, or great arterial levels

Question 2

• What is required to conclude that this child has an inno- cent heart murmur?

Answer 2

Three findings are necessary to make the diagnosis of inno- cent murmur in a child.
First, the examiner must recognize With confidence the classic auscultatory features of a specif- ic innocent murmur. A summary of characteristics that help identify these murmurs is presented in Table 1.

Second, a careful, cardiac-specific history must reveal no compelling evidence of heart disease.

Third, a careful, cardiac-specific physical examination (beyond simple auscultation of the heart) must reveal no compelling evidence of heart disease. Laboratory testing is not necessary to make the diagnosis of innocent murmur in the vast majority of cases

Question 3

• What elements of the history are important in the eval- uation of heart murmur?

Answer 3

Family History and Past Medical History

Question 4

What are some examples of innocent murmurs?

Answer 4

Still’s
Pulmonary flow
Pulmonary branchVenous hum

Supraclavicular bruit

Cardiorespi- ratory

Mammary souffle

Question 5

Still’s

Answer 5

Systolic ejection; slightly lateral to left lower sternal border

Vibratory, musical, like a low-pitched stringed instrument

Diminishes in intensity with inspiration, sitting up, or standing

Although it can occur at any age, it is particularly common in young school-age children, often detected at the kinder- garten physical; it is accentuat- ed by fever or other high car- diac output states

Harmonic vibrations of the left ventricular outflow tract

Question 6

• What elements of the physical examination are re- quired to evaluate this murmur?

Answer 6

Physical examination in this setting must include careful aus- cultation of the murmur With attention to timing, location, radiation, pitch, intensity, character, and alterations in the mur- mur With changes in posture. Furthermore, one must evaluate the character of heart sounds, listen closely for accompanying clicks, gallops, and rubs, and palpate the precordial impulses and the pulses in the upper and loWer extremities. Vital signs must be measured, including heart rate (and regularity), respi- ratory rate (and observation for cardinal features of respiratory distress: grunting, flaring, and retractions), blood pressure (upper and loWer extremities), and height and Weight (plotted on a groWth chart). The patient’s general appearance must be observed for features suggestive of dysmorphic syndrome or chromosomal abnormality, distress of any kind, cyanosis, pal- lor, diaphoresis, and abnormalities of peripheral perfusion. The respiratory examination should include evaluation for chest deformities as Well as auscultation for adventitial sounds (rales, Wheezes, rhonchi, pleural rubs) and for discrepant breath sounds on the right versus left sides. The gastrointesti- nal examination should include palpation for the location of the liver (abdominal situs), the size of the liver and spleen, and the presence of ascites.

Question 7

Common Cardiac Conditions Presenting as Murmur

Answer 7

Ventricular septal defect—small muscular
Pulmonary valve stenosis
Aortic valve disease
Ventricular septal defect—large and/or not muscular
Atrial septal defect
Patent ductus arteriosus
Mitral valve disease
Coarctation of the aorta
Subaortic stenosis
Tetralogy of Fallot
Atrioventricular septal defect

Question 8

Echocardiography

Answer 8

Echocardiography is an exquisitely accurate means for diag-
nosis of congenital heart disease When technologists trained and practiced in the pediatric examination perform the test using equipment suitable for children and When the test is interpreted by pediatric echocardiographers

Question 9

Because all of the common left-to-right shunt lesions (eg,
ventricular septal defect, atrial septal defect, patent ductus arteriosus) except for isolated secundum type atrial septal defect are believed to carry risk for bacterial endocarditis

Question 10

A 7-year-old child presents with a systolic murmur localized at the left lower sternal border during a routine physical examination. There are no accompanying symptoms or history of illness. Which of the following features, if present, would most strongly suggest that this is an innocent murmur?**

• A. Murmur is pansystolic
  
  • B. Murmur radiates to the neck
  • C. Murmur diminishes with sitting up
  • D. Murmur is associated with an early systolic click

Answer 10

• A. Murmur is pansystolic
  
  • B. Murmur radiates to the neck
  • C. Murmur diminishes with sitting up
  • D. Murmur is associated with an early systolic click

Question 11

A 3-year-old child is diagnosed with a “continuous machinery-like murmur” heard best in the infraclavicular region. Which congenital heart defect is most consistent with this description?*

• A. Ventricular septal defect (VSD)
  
  • B. Patent ductus arteriosus (PDA)
  • C. Atrial septal defect (ASD)
  • D. Tetralogy of Fallot

Answer 11

• B. Patent ductus arteriosus (PDA)

Question 12

During a physical examination, you note a child has a widely split and fixed S2 sound on auscultation. What is the most likely diagnosis?**
- A. Ventricular septal defect
- B. Coarctation of the aorta
- C. Atrial septal defect
- D. Mitral valve prolapse

Answer 12

• Answer: C. Atrial septal defect

Question 13

For a pediatric patient presenting with a heart murmur but otherwise normal development and health, which of the following features in the history or physical examination warrants further investigation for possible pathological murmur?**
- A. Murmur is soft and grade 1-2/6
- B. Diastolic component present in the murmur
- C. Absence of any symptoms such as syncope or cyanosis
- D. Murmur only audible when the child is febrile

Answer 13

Answer: B. Diastolic component present in the murmur

Question 14

In a child suspected of having an innocent Still’s murmur, what characteristic feature would typically be noted during auscultation?**
- A. Harsh quality
- B. Vibratory, musical quality
- C. High-pitched, blowing quality
- D. Continuous throughout systole and diastole

Answer 14

• Answer: B. Vibratory, musical quality

Question 15

A 4-year-old with no significant past medical history is found to have a new systolic murmur. There is no evidence of cardiac anomaly on initial history and physical examination. What is the next appropriate action?**
- A. Immediate referral for echocardiography
- B. Reassurance and routine follow-up
- C. Obtain a chest X-ray for further evaluation
- D. Referral to a pediatric cardiologist for consultation

Answer 15

Answer:** B. Reassurance and routine follow-up

Question 16

*What important family history elements should be assessed when evaluating a child with a newly discovered heart murmur?**
- A. Congenital heart defects in relatives
- B. History of rheumatic fever in the family
- C. Early sudden cardiac death
- D. All of the above

Answer 16

• Answer: D. All of the above

Question 17

Which innocent murmur is commonly found in preschool children and is known to be accentuated by conditions of increased cardiac output such as fever or anxiety?**
- A. Venous hum
- B. Innocent pulmonary flow murmur
- C. Mammary souffle
- D. Supraclavicular bruit

Answer 17

Answer: B. Innocent pulmonary flow murmur

Question 18

Prevalence and Types: Heart Murmurs

Answer 18

Innocent murmurs are common in children, with up to 72% of school-age children showing these during physical exams.

• There are seven main types of innocent murmurs: Still’s murmur, innocent pulmonary flow murmur, innocent pulmonary branch murmur of infancy, supraclavicular bruit, venous hum, mammary souffle, and cardiorespiratory murmur.

Question 19

Recognition and Diagnosis
of heart murmurs?

Answer 19

Recognizing an innocent murmur involves identifying the classic auscultatory features, taking a thorough history, and conducting a detailed physical examination without evidence of heart disease.

• No laboratory tests are needed to diagnose innocence for most cases.

Question 20

History & Considerations for Heart Murmurs?

Answer 20

• A detailed family history is critical, focusing on congenital heart defects and hereditary conditions that may predispose to heart issues.
  • Inquiries should be made about exercise tolerance, growth patterns, respiratory symptoms, dizziness, syncope, or palpitations which could suggest underlying heart problems.

Question 21

Physical Examination for Heart Murmurs?

Answer 21

• Key exam features include reviewing the timing, location, radiation, pitch, and intensity of the murmur.
  • Evaluate heart sounds, precordial impulses, and peripheral pulses. Check for distress, cyanosis, or any signs indicative of syndromes associated with cardiac anomalies.

Question 22

Red Flags for Pathological Murmurs?

Answer 22

• Consider referrals for any diastolic murmurs, those associated with clicks or abnormal heart sounds, continuous murmurs, and loud harsh murmurs.
  • Pathologic murmurs have characteristics such as configuration (pansystolic), location (left upper sternal), or longevity unaffected by postural changes.

Question 23

**Diagnostic Approaches? for Heart murmurs?

Answer 23

Options include chest X-ray, electrocardiogram (EKG), echocardiography, or referral to a pediatric cardiologist for further evaluation.

• Echocardiography, although expensive, offers definitive diagnosis.
• Referral to a pediatric cardiologist is often preferred for assessment, particularly if combined with selective echocardiography.

Question 24

Common Diagnostic Outcomes in Pathologic Murmurs:**

Answer 24

• Congenital heart disease less common but significant, includes conditions like ventricular septal defects (VSD), atrial septal defects (ASD), patent ductus arteriosus (PDA), pulmonary or aortic stenosis.
  • Management includes observation, prophylaxis against bacterial endocarditis for some conditions, and potentially surgical intervention.

Question 25

Management of Identified Conditions:**

Answer 25

• Many congenital defects, especially small shunts, may resolve themselves and necessitate immaterial management.
  
  • Increased risk for bacterial endocarditis exists with several defects, necessitating education on antibiotic prophylaxis.
  • Watchful monitoring is significant, and interventions for severe conditions may include catheter-based or surgical repair, considering the specific lesion characteristics and associated risks.

Question 26

Risks and Counseling for heart murmurs?

Answer 26

• Educate the family effectively to mitigate the anxiety concerning “cardiac nondisease,” where worries may unnecessarily restrict children.
  
  • Ensure families understand the nature and implications of innocent versus pathologic murmurs to prevent undue concern.