Listen for and identify heart murmurs: include auscultation in supine, sitting, and standing positions
Benign murmurs
- Always systolic
- Low pitched, “vibratory” or “musical” (not “harsh”)
- Heard only over a small area of the precordium
- Louder in the supine position
- Severity is less than 3 out of 6 (not associated with a thrill)
Pathological murmurs (require cardiology referral)
- Associated with cardiac symptoms such as cyanosis
- Associated with bounding or weak peripheral pulses
- Presence of abnormal heart sounds
- Diastolic murmurs are always pathological
- Loud systolic murmurs that have an intensity >3 out of 6 (ie., with thrill), long duration, and radiate
- Abnormal cardiac silhouette or abnormal pulmonary markings on chest x-ray
- Abnormal EKG findings
Physical exam findings suggestive of a CHD in neonates
- Cyanosis, particularly if it does not improve with O2 administration
- Weak or absent peripheral pulses in the lower extremities
- Irregular cardiac rhythm or abnormal heart rate
- Tachypnea 60 or more breaths per minute with/without retractions
- Hepatomegaly
- Heart murmur (benign heart murmurs are more common)
Ask about chest pain
- Cardiac causes make up only 1% of chest pain in children.
- A thorough history and physical exam are warranted in all cases.
- Referral to a pediatric cardiologist is required when:
- Patient presents with exertional chest pain
- Pain is associated with palpitations, dizziness, or syncope
- There are abnormal findings on physical exam, chest x-ray, and/or EKG
- There is a family history of:
- Sudden unexpected death
- Hypertrophic cardiomyopathy
- Long QT syndrome
- Hereditary diseases with associated cardiac defects
- Pain is chronic and/or recurrent and is a cause of significant worry for the patient and their family