The acyanotic child with a murmur who appears well and has an otherwise normal physical examination, most likely has a clinically insignificant murmur, indicating a mild acyanotic cardiac lesion such as small atrial or ventricular septal defects ( Table 35.3 ) If the examining provider is satisfied that the murmur is benign, further workup and specialty consultation are not indicated while the child is in the ED Additional evaluation can be determined by the child’s outpatient primary care provider If uncertainty exists, an EKG and CXR can be ordered If these are normal, one has further assurance that primary care followup is all that is necessary If either of these tests is abnormal, a more severe acyanotic defect is possible and echocardiography should be obtained Referral should be made to a pediatric cardiologist on a nonemergency basis for further characterization If the acyanotic child appears acutely ill (Fig 35.2A ), has a history of recent illness, swollen, red, or tender joints, and signs or symptoms of heart failure, acute rheumatic fever should be strongly considered The child should be hospitalized for evaluation of acute rheumatic fever (see Chapter 86 Cardiac Emergencies ) including cardiology consultation and echocardiography In contrast, the ill-appearing acyanotic child, with joint findings but without signs of cardiac failure or EKG changes, is more likely to have a normal murmur with a concurrent illness such as septic, reactive, or rheumatologic arthritis These children need diagnostic evaluation of their acute illness but only primary care follow-up for their murmur