An asymptomatic 8-year-old boy is found to have an ejection systolic murmur best heard at the right second intercostal space, radiating to the carotid arteries, with a soft single second sound. Blood pressure is 118/78 mmHg. The MOST likely diagnosis is:

• A Valvar aortic stenosis ✓
• B Valvar pulmonary stenosis
• C Coarctation of the aorta
• D Small ventricular septal defect

Explanation

B systolic murmur at the right upper sternal border radiating to the carotids with a soft, delayed aortic component of S2 indicates valvar aortic stenosis, usually due to a bicuspid valve. Pulmonary stenosis is heard at the LEFT upper sternal border and radiates to the back, which kills that distractor. Coarctation would show hypertension with radio-femoral delay, and a small VSD gives a pansystolic murmur at the lower left sternal border.

Reference: Park's Pediatric Cardiology for Practitioners, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.