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Widened pulse pressure
2%
1/64
Pansystolic, harsh, vibratory murmur loudest at the left lower sternal border
84%
54/64
Crescendo-decrescendo murmur that radiates to the neck and axilla
High-pitched blowing murmur that radiates to the axilla
3%
2/64
Continuous machine-like murmur heard throughout the precordium
8%
5/64
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For a patient with a small ventricular septal defect (VSD), a common exam finding is a pansystolic, harsh, vibratory murmur loudest at the LLSB. VSDs are holes in the interventricular septum that can occur in either the membranous (more common) or the muscular portion of the septum. VSDs are the most common congenital heart defect. Small VSDs often close spontaneously with 40% thought to close by 3 years, and 75% by age 10. Large VSDs are more likely to be symptomatic and may present with symptoms of heart failure or failure to thrive. For asymptomatic patients, the typical management is routine surveillance. Indications for surgical closure include continued symptoms, failure to thrive, pulmonary infections despite appropriate prophylaxis, or if pulmonary hypertension persists into the second year of life. Frank and Jacobe review the management of heart murmurs in children and adolescents. They note that while most murmurs in children are non-pathologic, there are certain auscultatory findings that are concerning, including: holosystolic or diastolic murmur, grade 3 or higher murmur, harsh quality, abnormal S2, maximal murmur intensity at the upper left sternal border, systolic click, or increased intensity when the patient stands. Michel-Behnke et al document their experience with hybrid (intraoperative device placement) VSD closure in a series of 26 patients. They had an 88% success rate with three device removals (for arrhythmias), one transient pericardial effusion (counted as a success), but no procedure or device-related complications. Incorrect Answers Answer 1: Widened pulse pressure is characteristic of conditions that cause shunting directly from the aorta (e.g. PDA, Aortic regurgitation). Answer 3: A crescendo-decrescendo murmur which radiates to the neck and axilla is characteristic of aortic stenosis. Answer 4: A high-pitched blowing murmur which radiates to the axilla is characteristic of mitral regurgitation. Answer5: A continuous machine-like murmur heard throughout the precordium is characteristic of a patent ductus arteriosus.
5.0
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