Differentials
Atrial septal defect
SIGNS / SYMPTOMS
The murmur is usually higher up in the left parasternal region and results from flow across the pulmonic valve. Therefore, the murmur is much softer, mid or ejection systolic instead of holosystolic, and the second heart sound may have a wide and fixed (not changing with breathing) split.
INVESTIGATIONS
An echocardiogram will demonstrate the defect and site of shunting by color flow.
Patent ductus arteriosus
SIGNS / SYMPTOMS
Associated with a continuous systolic and diastolic murmur at the base of the heart.
INVESTIGATIONS
An echocardiogram will show the defect at the level of the ductus arteriosus.
Mitral regurgitation
SIGNS / SYMPTOMS
Mitral regurgitation results in a holosystolic murmur most prominent at the mitral area, and may radiate to the axilla or the lower left sternal border depending on the eccentricity of the mitral regurgitation jet.
INVESTIGATIONS
An echocardiogram will reveal posterior motion of valve leaflets during mid-systole without evidence of a ventricular septal defects.
Tricuspid regurgitation
SIGNS / SYMPTOMS
Tricuspid regurgitation results in a holosystolic murmur at the lower left parasternal region. A characteristic finding in tricuspid regurgitation shared with other right-sided murmurs is an increase in the murmur intensity with inspiration (Carvalho sign).
INVESTIGATIONS
An echocardiogram will demonstrate regurgitant flow across the tricuspid valve without evidence of a ventricular septal defect.
Pulmonic stenosis
SIGNS / SYMPTOMS
Ejection systolic murmur at the left upper parasternal border.
INVESTIGATIONS
An echocardiogram will demonstrate turbulence of color flow and a gradient across the pulmonic valve without evidence of a ventricular septal defect.
Tetralogy of Fallot
SIGNS / SYMPTOMS
Typical infant presents in the newborn period with a murmur and cyanosis. The diagnosis may have been made prenatally on fetal echocardiogram. Some infants present at a later age with increasing cyanosis, murmur, or hypercyanotic spells. May be associated with genetic syndromes such as DiGeorge syndrome.
Physical exam may reveal significant tachypnea and cyanosis in severe cases, an increased right ventricular (parasternal) impulse, a single second heart sound, and a harsh systolic ejection murmur heard best at the left sternal border. The intensity of the murmur depends on the degree of pulmonary stenosis and decreases with severe stenosis.
INVESTIGATIONS
Echocardiogram will show the presence of the 3 other key findings in addition to the ventricular septal defect (i.e., presence of pulmonic stenosis, overriding aorta, and right ventricular hypertrophy).
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