Cardiovascular examination and murmur assessment — formative SAQs

SAQ 1 (10 marks)

A four-year-old boy is brought to the clinic because his general practitioner heard a heart murmur at a routine check. He is thriving, asymptomatic and fully active. On examination he is pink and well, with normal brachial and femoral pulses, a blood pressure of 95/55 mmHg in the right arm and 98/58 mmHg in the legs, and an oxygen saturation of 99 per cent in the right hand and 98 per cent in the foot. The apex is undisplaced and non-heaving, there is no thrill, and the heart sounds are normal with a normally split second sound. There is a soft, short, vibratory systolic murmur of grade two at the lower left sternal edge that softens when he sits forward. ^{[1] [4]}

a) Describe the murmur, state whether it is innocent or pathological, and give the reasons for your call. (3 marks) ^[1]

b) Outline the systematic cardiovascular examination you would perform in any child with a murmur, naming the five auscultation areas and the two bedside measurements that must never be omitted. (3 marks) ^{[1] [4]}

c) Give the diagnosis, state what further investigation is needed, and explain to the family what the murmur means and the safety-net for return. (2 marks) ^[1]

d) Contrast this murmur with a pansystolic murmur at the lower left sternal edge in a six-week-old infant, naming the likely lesion and the features that would suggest a large defect and heart failure. (2 marks) ^[1]