Child with a murmur

 

Assessment:

 

Innocent

Pathological

Hx

HOPC:

·      No cardiac symptoms

·      Normal exercise tolerance

PMHx:

·      Otherwise healthy

FHx:

·      Nothing

HOPC:

·      Dyspnoea, syncope, palpitations

·      Poor exercise tolerance

·      Cyanotic episodes

PMHx:

·      Congenital defect

·      Frequent “respiratory infection”

FHx:

·      Congenital heart disease

·      Sudden death

Ex

·      Normal growth

·      Normal vital signs

·      Strong femoral pulse

·      Murmur: soft, mid-systolic

·      Failure to thrive

·      Cyanosis

·      Weak femoral pulse

·      Murmur: loud, pan-systolic, diastolic

·      Extra heart sounds

·      Praecordial heave

·      Heart failure

·      (Infective endocarditis if dental abscess)

Ix

·      Normal ECG: quasi RVH

o   Fast heart rate

o   Short conduction intervals

o   Right axis deviation

o   Dominant R wave or RSR’ in V1

o   T wave inversion V1-3

Note ECG is rarely helpful

·      Abnormal ECG

Plan

·      GP review 1/12

·      ± Cardiology OPD

·      If proceeding: bedside TTE

·      If not: formal TTE + cardiology OPD

·      If unwell: refer for admission

 

Considerations:

Patient

·      Innocent vs pathological features

·      Possible underlying diagnosis

Family

Discuss with parents

·      Impact of child’s illness

·      Waiting time

·      Distance from hospital

Surgery

Discuss with surgeons

·      Urgency

·      Cardiovascular insult

Hospital

·      Cardiologist available?

·      HDU/ICU available

 

 

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