November Week 4: Heart Murmurs


Evaluation and management of heart murmurs in children. Frank JE, Jacobe KM. Am Fam Physician. 2011 Oct 1;84(7):793-800.

Pediatrics In Review. Consultation with the Specialist : Evaluation of Heart Murmurs. Vol. 15 No. 12December 1, 1994 pp. 490 -493 (doi: 10.1542/pir.15-12-490)


Case 1:

A 3 week old male infant presents with parents to clinic for his biweekly well child exam. Parents report that he initially fed very well, breastfeeding exclusively, but has recently begun to tire out with feeds. He at times appears sweaty and breathes too quickly for the parents to count. On the infant’s growth chart, he has not yet regained his birth weight, and is now 12% below.
On exam, vital signs are stable, with normal respirations and heart rate. A 3/6 continuous systolic ejection murmur is auscultated with an active precordium.

1. What is your differential for this infant’s presentation?
2. What would be your initial workup to rule in/rule out your most concerning diagnoses?
3. Would you refer this patient to pediatric cardiology, if so, how soon?

Case 2:

A 14 year old male presents to your clinic with his father for a sports physical. He is about to try out for the football team in the fall. He denies any chest pain or shortness of breath with exercise; however, he recently had one episode of fainting on the field after a long day in the sun. He remembers occasional palpitations just prior to the episode, none since. 
On exam, patient has a low resting heart rate, mildly increased blood pressure for age, vital signs otherwise stable. A systolic ejection crescendo-decrescendo murmur, which is best heard between the apex and left sternal border is heard and seems to lessen when the patient squats during the exam.

1. What further questions do you have for this patient and his father?
2. What is your differential for his presentation?
3. What is the significance of having the patient squat?
4. What tests would you like to perform in the office? 
5. Would your refer this patient to pediatric cardiology?

Case 3:

A 3 year old female presents to your office with parents for a well child exam. They recently moved to DC and are about to send their daughter to preschool. She was previously healthy with the exception of occasional colds and two episodes of bronchiolitis in the past that required hospitalization. Vital signs in clinic are stable, patient is very well appearing.
On exam, the toddler has a 2/6 low pitch systolic ejection murmur heard best at the left lower sternal border.
1. What maneuvers can you do in clinic to see if this murmur is benign or pathologic?
2. What questions do you have for parents to help determine if this murmur is concerning?
3. What is on your differential for this patient’s murmur
4. What can you tell parents to reassure them, what further workup is needed for this murmur?
5. When would you decide to refer to pediatrics cardiology?

Cases written by Dr. Rachel Sharret