_ dr-khmer: lets being a pediatrician............. - drkhmer

[ArchivalUser]

1_ During an annual visit, a 5-year-old boy is noted to have a heart murmur. The murmur is soft systolic, grade II in intensity, best heard along the left lower sternal border, and does not radiate. The murmur decreases in intensity in the sitting position. The first and second heart sounds are normal and no gallop is heard. The patient is an active child with no symptoms of tiredness or breathlessness, and he has a good appetite. He was hospitalized as
an infant for bronchiolitis. There is no other history of lung infections. His weight and height parameters are at the fiftieth percentile. Lung examination reveals good breath sounds and no rales. There is no hepatomegaly or peripheral edema. The parents are concerned when they are told about the murmur. Which of the following is themost appropriate next step in management?
(A) Obtain a chest x-ray
(B) Obtain a hematocrit
© Perform an electrocardiogram
(D) Reassure the parents that the child is healthy
(E) Send the child for an echocardiogram

[ArchivalUser]

(D) Reassure the parents that the child is healthy

[ArchivalUser]

dd

[ArchivalUser]

EEEE: send for echo

[ArchivalUser]

ee..

[ArchivalUser]

Innocent murmur...(D) Reassure the parents that the child is healthy

[ArchivalUser]

_ The correct answer is D. Nearly one third of children may have an innocent murmur during routine examination. Such murmurs are not associated with hemodynamic abnormalities or cardiac defects. They arise as a result of normal turbulence of blood in the chambers of the heart or large vessels during childhood. Innocent murmurs are characterized by their character (short systolic), low intensity (grade I or II), and absence of any other abnormal physical signs. No further investigation is required in such children, and parents can be reassured regarding the benign nature of the finding.
A chest x-ray (choice A) is useful to evaluate heart size when cardiac failure is suspected. It also can show abnormal cardiac shape in certain congenital cardiac lesions. It is not required in the case presented in the vignette.
Children with anemia have hyperdynamic circulation and can demonstrate cardiac flow murmurs. In an otherwise healthy child, however, the presence of murmur alone does not require obtaining a hematocrit (choice B). Instead, hematocrit should be performed at 1 year
of age and before school entry as part of the routine health maintenance.
Cardiac disease can be suspected from history of tiredness, breathlessness, or growth failure. In addition, there are features in physical examination that can help to identify children with heart murmur who have a cardiac disease. These include a pansystolic murmur, very loud murmurs (grade III or greater), presence of click, or an abnormal second heart sound. In the absence of any of these features, an electrocardiogram (choice C) or echocardiogram (choice E) is not required.

[ArchivalUser]

d.