Differentials
Innocent murmur
SIGNS / SYMPTOMS
Asymptomatic.
On auscultation, systolic murmur, usually softer and shorter compared with PS, no ejection click.
INVESTIGATIONS
Echocardiography with colour Doppler: normal cardiac and physiology.
Straight back syndrome
SIGNS / SYMPTOMS
On auscultation, no ejection click but systolic right ventricular (RV) outflow track murmur along left upper sternal border.
INVESTIGATIONS
Echocardiography with colour Doppler: normal cardiac anatomy and physiology.
Lateral chest x-ray: abnormally straight spinal curve.
Idiopathic dilation of pulmonary artery
SIGNS / SYMPTOMS
On auscultation, softer systolic murmur.
INVESTIGATIONS
Echocardiography with colour Doppler: morphologically normal pulmonary valve, dilated pulmonary artery.
Pulmonary artery stenosis
SIGNS / SYMPTOMS
On auscultation, mid-to-late systolic murmur, radiating to the back and lateral lung fields, no ejection click.
INVESTIGATIONS
Echocardiography: stenotic pulmonary artery.
Aortic valve stenosis
SIGNS / SYMPTOMS
On auscultation, systolic ejection murmur in upper right sternal border, radiating into carotids and left ventricular apex.
INVESTIGATIONS
Echocardiography with colour Doppler: stenotic aortic valve.
Atrial septal defect (ASD)
SIGNS / SYMPTOMS
On auscultation, systolic RV outflow track murmur of functional PS, wide and fixed splitting of S2, no ejection click.
INVESTIGATIONS
Echocardiography: morphologically normal pulmonary valve but abnormal findings of atrial septum; colour Doppler: left-to-right shunting.
Ventricular septal defect
SIGNS / SYMPTOMS
On auscultation, pansystolic regurgitant murmur typically at lower sternal border; can be difficult to distinguish from PS murmur.
INVESTIGATIONS
Echocardiography with colour Doppler: left-to-right interventricular septal blood flow.
Ebstein's anomaly
SIGNS / SYMPTOMS
Active pre-cordium; on auscultation, softer systolic murmur at lower left sternal border, sometimes 'quadruple' rhythm.
INVESTIGATIONS
Chest x-ray: cardiomegaly, decreased pulmonary vascular markings.
ECG: reduced voltage, right bundle branch block, right atrial enlargement; echo: apically displaced septal leaflet, redundant anterior leaflet of tricuspid valve.
Tetralogy of Fallot
SIGNS / SYMPTOMS
Cyanosis more pronounced than in PS; usually no ejection click as stenosis lies below level of valve or is due to small pulmonary annulus.
INVESTIGATIONS
Chest x-ray: decreased pulmonary vascular markings, uptilted right ventricular apex.
Echocardiography with colour Doppler: aortic override, ventricular septum defect.
Pulmonary valve atresia with intact ventricular septum
SIGNS / SYMPTOMS
Progressive cyanosis; on auscultation, no PS murmur as all the pulmonary blood flow is via ductus arteriosus.
INVESTIGATIONS
Echocardiography with colour Doppler: atresia of pulmonary valve, blood flow via ductus arteriosus.
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