Context Choose one First line
New murmur Previously noted murmur
Assessment Choose one
Murmur with features of an innocent murmur: soft, systolic, normal heart sounds, and normal pulsesDefault Soft vibratory systolic murmur, louder lying down, consistent with a Still's murmur Soft systolic murmur at the upper left sternal border consistent with a pulmonary flow murmur Continuous murmur below the clavicle that disappears lying down, consistent with a venous hum Soft systolic murmur radiating to the back and axillae in an infant, consistent with peripheral pulmonary stenosis Murmur with features that are not clearly innocent
Concerning features present Choose any
a loud murmur or thrill a diastolic murmur a click or abnormal second heart sound weak femoral pulses cyanosis poor feeding, poor growth, or sweating with feeds a murmur louder on standing chest pain with exercise or fainting family history of cardiomyopathy or sudden cardiac death
Concerning features absent Choose any
loud murmur or thrillDefault diastolic murmurDefault click or abnormal second heart soundDefault weak femoral pulsesDefault cyanosisDefault poor feeding, poor growth, or sweating with feedsDefault a murmur louder on standingDefault symptoms with exercise or faintingDefault family history of cardiomyopathy or sudden cardiac deathDefault
Plan Choose one
Reassurance provided; no testing or activity restrictions neededDefault Referred to pediatric cardiology for evaluation Referred to pediatric cardiology to confirm an innocent murmur given age younger than 6 months Referred to pediatric cardiology to confirm an innocent murmur given family preference Echocardiogram ordered to confirm normal heart structure
Disposition Choose one
Sent to the emergency department given concerning features
Follow-up Choose one
at the next well child checkDefault after the cardiology visit after the echocardiogram
Follow-up reason Choose any Joins the line above
recheck the murmurDefault
Counseling paragraph Choose one Paragraph
Innocent murmurs are very common in healthy children, come from normal blood flow through the heart, and often sound louder with fever, excitement, or growth before fading over time. They need no treatment, no special testing, and no limits on activity. Return precautions given including trouble breathing, poor feeding or weight gain, sweating with feeds, blue color of the lips, fainting, chest pain with exercise, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.Default The heart evaluation will check the structure of the heart; most murmurs in children turn out to be innocent. Return precautions given including trouble breathing, poor feeding or weight gain, sweating with feeds, blue color of the lips, fainting, chest pain with exercise, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions. A referral to confirm an innocent murmur does not mean the murmur is abnormal; most murmurs in children turn out to be innocent. Return precautions given including trouble breathing, poor feeding or weight gain, sweating with feeds, blue color of the lips, fainting, chest pain with exercise, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.
Counseling Not in the note with these choices
Discussed the need for emergency evaluation today. Caregiver expressed understanding and agreement with plan. Answered all questions.
Note when inserted as is
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Murmur
• Murmur with features of an innocent murmur: soft, systolic, normal heart sounds, and normal pulses
• No loud murmur or thrill, diastolic murmur, click or abnormal second heart sound, weak femoral pulses, cyanosis, poor feeding, poor growth, or sweating with feeds, a murmur louder on standing, symptoms with exercise or fainting, or family history of cardiomyopathy or sudden cardiac death
• Reassurance provided; no testing or activity restrictions needed
• Follow up at the next well child check to recheck the murmur
Innocent murmurs are very common in healthy children, come from normal blood flow through the heart, and often sound louder with fever, excitement, or growth before fading over time. They need no treatment, no special testing, and no limits on activity. Return precautions given including trouble breathing, poor feeding or weight gain, sweating with feeds, blue color of the lips, fainting, chest pain with exercise, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.