Heart murmurs

Haemodynamic compromise from acute bleeding → resuscitate as GI bleed

Acute severe AR (aortic dissection or endocarditis) → emergency surgery — poorly tolerated, do not delay

Onset of symptoms (syncope/angina/dyspnoea) in severe AS → urgent referral for valve replacement (poor prognosis untreat

Paradoxical embolic stroke (a venous clot crossing the defect)

Critical neonatal coarctation presenting as collapse when the duct closes → PROSTAGLANDIN to reopen/maintain the duct +

Congenital heart disease (~50% — AVSD), duodenal atresia, Hirschsprung; later — leukaemia, hypothyroidism, atlantoaxial

Exertional syncope, family history of sudden death, massive LVH, non-sustained VT or abnormal BP response → high sudden-

Acute S. aureus IE with valve destruction → heart failure/cardiogenic shock → emergency surgery

RED-FLAG features that mean refer/echo (NOT innocent): diastolic murmur, pansystolic, loud (≥grade 3)/thrill, harsh, abn

Acute severe MR from papillary muscle rupture (days after an inferior MI) → cardiogenic shock → emergency surgery

AF with systemic embolism (stroke) — anticoagulate; mitral stenosis AF needs warfarin, not a DOAC, if rheumatic/moderate

Large PDA with heart failure (especially preterm) → treat/close

Critical neonatal PS → prostaglandin (duct-dependent) + intervention

Severe carditis with heart failure → admit and treat

Right-sided endocarditis in an IV drug user → blood cultures, echo, antibiotics ± surgery

S. aureus bacteraemia → always seek a source (echo for endocarditis, MRI spine for discitis) — never dismiss as a contam

Hypercyanotic 'tet' spell → knee-chest position, oxygen, morphine, IV fluids, beta-blocker/phenylephrine — can be life-t

Heart failure in infancy (large VSD) → diuretics + surgical closure

Hypotension/tamponade, neurological deficit, or a widened mediastinum on chest X-ray → immediate imaging and cardiothora

Heart failure + early pulmonary hypertension (complete AVSD) → timely surgical repair

Eisenmenger physiology → avoid pregnancy and systemic vasodilators; refer to specialist adult congenital heart disease (

Severe neonatal Ebstein (cyanosis + heart failure) → intensive care ± prostaglandin

ABSENT RED REFLEX → urgent referral (congenital cataract / retinoblastoma)

Right heart failure/syncope → specialist pulmonary hypertension centre

Profound day-1 cyanosis → emergency: PROSTAGLANDIN (keep the duct open) ± balloon atrial septostomy

Duct closure → worsening cyanosis → prostaglandin

Early heart failure and pulmonary hypertension → timely surgery

2-week-wait referral: age ≥40 with weight loss + abdominal pain; ≥50 with rectal bleeding; ≥60 with iron-deficiency anae

Rectal bleeding with change in bowel habit, weight loss, anaemia, or age ≥50/≥60 → investigate for COLORECTAL CANCER, do