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Case 1 A 23 month-old toddler is seen for failure to thrive with a murmur. She is pink and alert, in no distress.

Her vital signs are normal, including all blood pressure. Precordial activity, pulses and abdomen are all normal. S1 is normal, and S2 is physiologically spilt and of normal intensity. A 2/6 vibratory systolic murmur and 1/6 short, early, vibratory diastolic murmur are best midway between the middle left sternal border and apex. A 2/6 short, low medium frequency systolic ejection murmur is also heard at the upper left sternal border. All three murmurs diminish during inspiration and with the patient sitting up. Questions 1. What are the murmurs? 2. Do you think the failure to thrive is caused by cardiac disease? 3. What clues, even before the auscultation, indicate that the childs failure to thrive is not caused by caused by cardiac disease ? Case 2 A 3-year-old child has normal vital signs and is pink. His pulses and precordial activity are normal, as are his heart sounds. There is a 3/6 coarse,low-medium-frequency systolic ejection-type murmur,which obscures S2 and spills into diastole. It is best heard in the left infraclavicular area. A 1/6 middiastolic murmur is heard at the apex. The abdomen is normal. Questions 1. What lesions is typified by this murmur? 2. What is the estimated Qp:Qs ? Case 3 John, aged 13 years, had surgery for a complex congenital heart lesion 3 weeks ago and is found to have a slow heart rate. This is his ECG. 1. What is the ventricular rate ? 2. What is the atrial rate ? 3. What is Johns ECG diagnosis ?

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