You see a 2-month-old for a well-child visit. She is breastfed and nurses every 2 to 3 hours during the day, but her mother reports she is not nursing as vigorously as before. She sleeps one 4-hour block at night. Birth weight was 7 pounds 5 ounces. Weight gain over the last 2 weeks reveals gain of 5 ounces per week. Physical examination reveals the following: HEENT exam is benign, lung sounds are clear, a new III/VI systolic ejection murmur is noted along the left lower sternal border, cap refill is brisk, skin is pink and moist, and abdominal exam is benign. Questions an explanation of the differential diagnosis for the patient in the case study you selected. Explain which is the most likely diagnosis for the patient and why. Include an explanation of unique characteristics of the disorder you identified as the primary diagnosis. Then, explain a treatment and management plan for the patient, including appropriate dosages for any recommended treatments. Finally, explain strategies for educating patients and families on the treatment and management of the respiratory, cardiovascular, and/or genetic disorder.


In this case study, we encounter a 2-month-old infant who is breastfed and experiencing decreased nursing vigor. The infant also sleeps for a 4-hour block at night. The examination reveals the presence of a new III/VI systolic ejection murmur along the left lower sternal border. This paper aims to provide a thorough differential diagnosis for the patient and identify the most likely diagnosis. Additionally, a treatment and management plan will be outlined, along with strategies for patient and family education.

Differential Diagnosis

When considering the symptoms and physical examination findings in this case, it is important to develop a broad differential diagnosis. The primary differential diagnoses for the patient include congestive heart failure, congenital heart defects, and respiratory illness.

Congestive Heart Failure (CHF) is a potential diagnosis because of the presence of a new murmur, poor nursing vigor, and sleep pattern changes. CHF is characterized by an impaired ability of the heart to adequately pump blood to meet the metabolic demands of the body. Symptoms can include poor feeding, tachycardia, tachypnea, failure to thrive, and edema. An important characteristic of CHF in infants is the presence of hepatomegaly. This condition can be caused by various cardiac anomalies, such as ventricular septal defect (VSD) or patent ductus arteriosus (PDA).

Congenital Heart Defects (CHDs) often present with murmurs and can lead to symptoms such as poor feeding, failure to thrive, and respiratory distress. The murmurs are caused by abnormalities in the structure or function of the heart. Common examples of CHDs include VSD, atrial septal defect (ASD), and tetralogy of Fallot. Characteristics of specific CHDs should be considered when making a diagnosis.

Respiratory Illnesses should be considered due to the decreased nursing vigor and potential sleep disturbances. Respiratory illnesses such as bronchiolitis, pneumonia, or viral upper respiratory infections can cause a range of symptoms such as tachypnea, cough, and nasal congestion. These conditions can interfere with feeding and normal sleep patterns in infants.

Most Likely Diagnosis

Based on the information provided, the most likely diagnosis for this patient is a congenital heart defect, particularly a ventricular septal defect (VSD). The presence of the new systolic ejection murmur along the left lower sternal border is consistent with a VSD. VSDs are commonly observed in infants and are characterized by an abnormal communication between the ventricles. This results in the shunting of blood from the left ventricle to the right ventricle, which can lead to increased pulmonary blood flow and the development of symptoms such as poor feeding and failure to thrive.

Unique Characteristics of VSD

VSDs are one of the most common congenital heart defects in infants. They can range in size from small to large and vary in severity. Small VSDs often close spontaneously within the first year of life and may not cause significant symptoms. Larger VSDs can lead to congestive heart failure due to increased pulmonary blood flow. The severity of symptoms depends on the size of the defect and the degree of the shunting.

Treatment and Management Plan

The treatment and management of a VSD depend on the size of the defect, the degree of symptoms, and the presence of associated complications. In cases where the defect is small and not causing significant symptoms, a conservative approach with close monitoring may be appropriate. Regular follow-up visits should be scheduled to monitor the size and closure of the defect.

For larger VSDs causing symptoms such as congestive heart failure, pharmacological management may be necessary. Diuretics, such as furosemide, can be prescribed to reduce fluid overload and alleviate symptoms. Dosages and frequency of administration should be tailored to the individual patient’s needs, weight, and response to treatment.

In cases where the VSD is large and causing severe symptoms or complications, surgical intervention may be necessary. Surgical repair involves closing the ventricular septal defect using a patch or sutures. The timing of surgery depends on the severity of symptoms, the infant’s age, and the presence of associated anatomical abnormalities.

Strategies for Patient and Family Education

Patient and family education are crucial for understanding the treatment and management of a congenital heart defect like VSD. An important aspect of education is explaining the diagnosis and the implications it has for the individual’s long-term health. Visual aids, diagrams, and simplified explanations can be used to enhance understanding.

Additionally, discussing the treatment options and their potential benefits and risks can empower the family to make informed decisions. Clear instructions on medication administration, including dosages, timings, and potential side effects, should be provided. Furthermore, educating the family on the signs of worsening symptoms and when to seek medical attention is important for early intervention and prevention of complications.


In conclusion, the differential diagnosis for the 2-month-old infant in this case includes congestive heart failure, congenital heart defects (particularly VSD), and respiratory illnesses. The most likely diagnosis is a VSD based on the presence of a new systolic ejection murmur. Treatment and management plan options include conservative observation, pharmacological management with diuretics, or surgical intervention. Strategies for patient and family education should focus on understanding the diagnosis, treatment options, medication administration, and signs of worsening symptoms.