Innocent murmurs and normal paediatric cardiovascular variants — OSCE

Station brief (8 minutes)

You are the general paediatric registrar. A thriving 3-year-old has been referred because a murmur was heard at a routine check. The parent is anxious, has read about congenital heart disease online, and has been told the child may need a scan and should stop sport. Examine the child, explain your findings and reasoning, and agree a plan. [1]

Candidate tasks

1. Take a focused cardiac history (growth, feeding, exertion, colour, syncope, family history) and examine the child positionally, including heart sounds, femoral pulses and an oxygen saturation. [5]
2. Identify the finding as a Still's vibratory murmur and apply the red-flag filter to exclude pathology. [3]
3. Communicate the diagnosis, explain why no scan is needed, address the sport and activity question, and give a safety-net. [1] [2]

Examiner marking grid

Communication (3): Acknowledges parental anxiety; uses plain language ("the heart is structurally normal, this is a sound of normal blood flow"); invites questions; checks understanding.

Clinical reasoning (4): Names Still's murmur with reasoning (thriving, soft vibratory lower-left-sternal-edge systolic murmur, softer upright, normal S2, normal femoral pulses, normal saturation); states the red-flag filter that excludes pathology (no diastolic/holosystolic/continuous, no thrill, no fixed split S2, no abnormal pulses, no symptoms). [1] [3]

Management (3): Confirms no echocardiogram, ECG or CXR is indicated; allows full activity with no restriction; gives no endocarditis prophylaxis and routine dental care; documents the specific finding and the reasoning; safety-nets for new symptoms (exertional intolerance, syncope, breathlessness, colour change, poor growth). [1]

Model script for the parent

"The sound I can hear is not caused by anything wrong with the heart. It is the normal sound of blood flowing through a healthy young heart in a small chest — it is very common in children this age and will go away as your child grows. I have checked the heart sounds, the pulses and the oxygen level, and they are all normal, which is why I am confident this is what we call an innocent murmur. Your child does not need a heart scan, does not need to stop sport, and does not need any special precautions. I would like you to bring them back if they ever get breathless, faint, go pale or blue with exercise, or are not growing well — but I do not expect that to happen." [1] [2]

Common pitfalls flagged by examiners

• Ordering an echocardiogram reflexively for a clearly innocent murmur. [1]
• Telling the family to restrict activity or give endocarditis prophylaxis. [1]
• Failing to check the splitting of S2 (the atrial septal defect trap) or the femoral pulses (the coarctation trap). [2]
• Not giving a clear, named safety-net for new symptoms. [3]