Heart Auscultation Quiz
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4 year old girl, no symptoms. Normal growth and development. A quiet child, not as active as some other children. Examination: normal pulses, heart action is perhaps a little increased and maximal close to the left sternal edge. You listen at the left upper sternal edge.
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5.1 Heart rate is a bit increased with little variation with breathing, which is not normal.
5.2 S2 is widely split and does not vary with breathing
5.3 Systole: low pitch systolic ejection murmur 2/6
5.4 Diastole: no sounds
Conclusion: This child has a significant ASD with typical findings of a prominent right ventricular impulse, widely split and fixed S2 and almost rumbling systolic murmur in the “pulmonic” area. The heart rate is also a bit faster than you would expect and seems driven by some process to be unvarying with breathing, which is subtle but not normal. Pulmonary stenosis is also a possibility but would usually have a harsher murmur and the S2 split should increase with inspiration.
Many children with ASDs at this age seem to have few symptoms as they have compensated for the shunt, but this child is quiet and it might be difficult to discern whether she has breathlessness with exercise. You can appreciate that these findings could be missed in a routine examination of a healthy child and many patients with ASD are not diagnosed until adulthood. The wide S2 is really the hallmark of the abnormality on auscultation and should not be ignored.
If you find it “too easy” to hear the splitting then the patient needs referral. All of these findings need confirmation by a cardiologist and likely ASD closure by either device or surgery.
Her heart rate is:Correct
Your assessment of this child’s heart:Correct
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