murmur is heard EKG, electrocardiogram; PFO, patent foramen ovale; TOGV, transposition of great vessels; VH, ventricular hypertrophy Well appearing with normal physical exam other than presence of a murmur ? Normal EKG, CXR, or limited bedside cardiac ultrasound? 'i V Evaluate for other condition (flow murmur) Signs of heart failure? >' 'r ’f - Severe acyanotic CHF: Large VSD, large - Primary pulmonary disease PDA, severe aortic or pulmonary stenosis - Myocardial lesion: myocarditis, primary myocardial disease, anomalous origin of left coronary artery - Extracardiac cause: severe anemia, large AV malformation A Cyanotic child >1 yr with a murmur Well appearing with normal physical exam other than precordial findings? ' V Normal CXR/EKG /Limited bedside cardiac ultrasound and pulse oximetry \ '1 Noncardiac causes of apparent cyanosis with clinically insignificant murmur Abnormal CXR /EKG/Limited bedside cardiac ultrasound and pulse oximetry r \ ’ Possible cyanotic congenital cardiac defect ’< B - Polycythemia - Mild methemoglobinemia FIGURE 35.2 A: Assessment of a noncyanotic, sick child year or older in whom a murmur is heard B: Assessment of a cyanotic child year of age or older EKG, electrocardiogram Children Greater Than Year of Age With Murmur By the time children who have easy access to medical care reach year of age, most severe congenital lesions have been identified and many have been surgically repaired Therefore, acquired cardiac and noncardiac etiologies constitute a larger proportion of new murmurs in this age group Functional murmurs are by far the most commonly discovered murmurs in an older child Acyanotic Children Greater Than Year of Age