A 5-year-old boy is brought to the office for an annual physical examination. The child has been healthy and takes no medications. His maternal uncle died from a myocardial infarction at age 56. Height and weight are at the 50th percentile. Temperature is 36.7 C (98 F), blood pressure is 95/53 mm Hg, pulse is 92/min, and respirations are 20/min. He is well-appearing and alert. Auscultation of the chest shows a grade II systolic ejection murmur at the left lower sternal border. It is best heard when the child is lying down and decreases with standing. No rubs or gallops are heard. Which of the following is the best next step in management of this patient?

Question

A 5-year-old boy is brought to the office for an annual physical examination.  The child has been healthy and takes no medications.  His maternal uncle died from a myocardial infarction at age 56.  Height and weight are at the 50th percentile.  Temperature is 36.7 C (98 F), blood pressure is 95/53 mm Hg, pulse is 92/min, and respirations are 20/min.  He is well-appearing and alert.  Auscultation of the chest shows a grade II systolic ejection murmur at the left lower sternal border.  It is best heard when the child is lying down and decreases with standing.  No rubs or gallops are heard.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d244_be07_bc81_0f677994171d_MD0003_00 Most children will have an audible murmur at some point in their lives; the vast majority of these are benign. These murmurs are also described as innocent, functional, or physiologic and result from blood flow through a structurally normal heart. A key distinguishing feature from a benign versus a pathologic murmur is the change in intensity in response to positional changes. Maneuvers that decrease venous blood return to the heart (eg, standing, Valsalva maneuvers) typically reduce the intensity of innocent murmurs. This patient's murmur has no concerning features. He is otherwise asymptomatic, and his vital signs are normal. The patient's blood pressure is normal for his age, height, and sex, and he has no family history of heritable cardiac conditions. Therefore, the family should be reassured that the murmur is clinically insignificant. Further workup and cardiology referral (Choice A) are not required at this time. (Choice B) A chest-x-ray can be ordered in patients with respiratory symptoms to exclude pneumonia, pulmonary edema, or other lung pathology. It can also provide a rough estimate of a patient's heart size. (Choice C) An echocardiogram is indicated for pathologic murmurs that may be indicative of structural heart disease, such as congenital heart disease or hypertrophic cardiomyopathy. The murmur of hypertrophic cardiomyopathy increases, rather than decreases, with standing (standing decreases venous return and preload, increasing the obstruction). hypertrophic cardiomyopathy (Choice D) ECGs can help to diagnose hypertrophic cardiomyopathy by showing left ventricular hypertrophy. They are normal in most children with both benign and pathologic murmurs and are not an adequate screening test for congenital heart disease. hypertrophic cardiomyopathy (Choice E) A Holter monitor is a portable monitor worn by a patient for several days to detect arrhythmias. This child's history is not concerning for an arrhythmia. Educational objective: Innocent cardiac murmurs result from normal blood flow from a structurally normal heart. The intensity is typically grade I or II and decreases with standing. Benign murmurs are also early or mid-systolic in timing. Management consists of observation and reassurance. References: Evaluation and management of heart murmurs in children. (http://www.ncbi.nlm.nih.gov/pubmed/22010618) Evaluation of children with heart murmurs. (http://www.ncbi.nlm.nih.gov/pubmed/9791388)

A 5-Year-Old Boy Is Brought to the Office for an Annual