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Item 1 of 20Question Id: 6ec9

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A 12-year-old girl is brought to the clinic for a pre-participation physical examination before joining her school soccer team. She has no significant past medical history. Her maternal grandmother died from myocardial infarction at age 71. Vital signs are within normal limits. Auscultation of the chest shows a regular heart rate and rhythm. A high-pitched, grade I/VI systolic ejection murmur is heard at the left upper sternal border and becomes grade II/VI when the patient is supine. No rubs or gallops are heard. Which of the following is the best next step in the management of this patient?

A.Cardiology referral

B.Reassurance

C.ECG

D.Echocardiogram

E.Holter monitoring

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Correct

Key Points

Careful history-taking and examination are highly sensitive for pathologic causes of cardiac murmurs. Murmurs that are harsh, diastolic, or holosystolic, loud (grade III/VI or higher), or associated with symptoms should be evaluated. Conversely, soft systolic murmurs in asymptomatic children that increase when supine are usually innocent.

Why this is correct

The majority of murmurs heard in children and adolescents are benign. Distinguishing between innocent and pathologic murmurs is essential to avoid unnecessary anxiety and medical testing.

Characteristics of Innocent Murmurs

Innocent murmurs, such as the pulmonary flow murmur, are typically characterized by the following:

•Timing: Almost exclusively systolic.
•Quality: Soft, low-pitched, and non-harsh.
•Positional Changes: Typically increase in intensity when the patient is supine (lying down) due to increased venous return.
•Associated Symptoms: None; the patient is asymptomatic.

Red Flags for Pathologic Murmurs

Murmurs that require further investigation (ECG, echocardiogram, or cardiology referral) include:

•Timing: Any diastolic or holosystolic murmur.
•Intensity: Loud (Grade III/VI or higher) or harsh quality.
•Positional Changes: Systolic murmurs that increase with standing or Valsalva maneuvers.
•Family History: Early cardiac death or unexplained sudden death in relatives.

Management

For children with soft, systolic murmurs and no associated symptoms, the clinical diagnosis is an innocent murmur. The appropriate management is reassurance for the family, as the likelihood of underlying heart disease is extremely low.

Why other options are wrong

Cardiology referral is reserved for murmurs with pathologic features — diastolic, holosystolic, loud or harsh, associated with symptoms, or a concerning family history of early cardiac death. This is a soft, positional systolic murmur in an asymptomatic child, which does not meet that threshold.

An ECG is not indicated for a soft systolic murmur that increases when supine in an asymptomatic patient. It is reserved for murmurs that are diastolic, holosystolic, loud or harsh, or accompanied by symptoms — none of which are present here.

An echocardiogram is reserved for murmurs with pathologic features (diastolic, holosystolic, loud or harsh, symptomatic, or concerning family history), not for a soft, positional systolic murmur with an otherwise unremarkable history and exam.

Holter monitoring is used for suspected dysrhythmias. Generally, patients with dysrhythmia will describe syncope or presyncope, or a feeling of fluttering or palpitations. This patient is asymptomatic and has no evidence of dysrhythmia on cardiac auscultation.

References: Objective number 62-3 (Systolic Murmur) of Objectives for the Qualifying Examination, 3rd edition Frank JE, Jacobe KM. Evaluation and management of heart murmurs in children. Am Fam Physician 2011; 84:793.

A.Cardiology referral

B.Reassurance

C.ECG

D.Echocardiogram

E.Holter monitoring

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