Heart Auscultation Quiz
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9 year old boy, asymptomatic. Routine physical exam. Normal growth and development. Normal pulses and cardiac impulse. You listen at the left upper sternal border.
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9.1 S1 is normal but may be a bit loud
9.2 S2 is abnormal as it is widely split. Hard to say whether it varies with breathing
9.3 Systolic murmur is abnormal, not musical
9.4 Diastole is silent
9.5 Atrial septal defect and pulmonary valve stenosis (both b and c)
Conclusion: This child has either an atrial septal defect or pulmonary stenosis. The wide split of S2 is always abnormal and is related to delayed emptying of the right ventricle either due to increased volume (ASD) or increased pressure (PS). In some patients there is an ejection click from the stenotic valve but this is not clear in this case.
An ECG is useful in making the distinction as well but echocardiography is essential. If it is pulmonary stenosis a valve gradient of 50mm or more would be treated with a catheter balloon dilation, while an ASD would require either a device closure or surgery.
Your assessment of this child’s heart:Correct
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