Immediate Questions

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A. Is there cyanosis? Congenital heart disease with right-to-left shunting or single-ventricle physiology produces cyanosis that persists despite administration of supplemental oxygen.

B. Are there signs and symptoms of heart failure? Symptoms of heart failure in infants include slow feeding, tiring with feeding, or diaphoresis associated with feeding. Signs of heart failure in this age group are resting tachycardia and tachypnea.

C. Has this murmur been noted previously? A murmur from a left-to-right shunting lesion, such a ventricular septal defect, presents as the pulmonary vascular resistance falls and a gradient develops between the systemic and pulmonary circulations (usually in the first week of life). Murmurs due to valve stenosis typically are present from birth. A murmur attributed to carditis (associated with Kawasaki disease, rheumatic fever, endocarditis, or myocarditis) would be a new finding, in association with other systemic signs.

D. Are there other systemic signs or symptoms? Persistent fever, conjunctivitis, rash, extremity changes, and lymphadenopathy are seen in Kawasaki disease. Joint swelling and pain in association with a new murmur in an older patient could be indicative of acute rheumatic fever. Evidence of bacteremia with persistent fever and a new or changing murmur may suggest infective endocarditis. Failure to thrive may be associated with chronic volume overload, heart failure, or pulmonary hypertension.

E. Is there a history of prematurity? Premature infants, especially those with low birth weight, are more likely to have persistent patent ductus arteriosus.

F. Has there been a prior cardiac evaluation? Many patients with congenital heart disease are identified prenatally by fetal echocardiography and have had subsequent postnatal evaluations. Information from any prior cardiac evaluations, including findings of diagnostic tests, should be reviewed.

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