Heart Auscultation Quiz

Answers

1.1 Heart rate increased
1.2 S2 widely split and fixed
1.3 Systolic ejection murmur, abnormal
1.4 Diastole is silent
1.5 Diagnosis – ASD

This child has a number of abnormal physical findings despite a normal history. He is a bit small for his age. His heart rate is a bit fast for his age. He has an increased right ventricular impulse suggesting volume or pressure increase in that ventricle. His heart sounds are abnormal. So before you even listen, you should suspect a heart abnormality.

The widely split S2 is never normal (you will need experience to assess this finding confidently at the faster heart rate of a child; listen to some normal pediatric recordings or children to compare with normal). The wide S2 in children likely indicates either atrial septal defect or pulmonary stenosis. If you can be sure the wide S2 is not varying with respiration, ASD is most likely. The systolic murmur over the pulmonary area in this child is ejection, and it is not musical. So it is abnormal. It is not harsh (like the sound “sh”) so not caused by a high pressure gradient across the pulmonary valve but more likely to increased flow across the valve from a shunt, likely an ASD. Diastole is silent but in some patients there is a faint mid diastolic murmur due to the increased flow across the tricuspid valve in diastole. This is due to the left to right shunt across the ASD which is directed through the tricuspid valve.

Not all ASDs have these “classical findings” so many are missed in children to be discovered in adulthood. The wide split of S2 is often missed and if the murmur is soft it may not alert suspicion, especially in an apparently asymptomatic child. Interestingly most children who seem normal and active before ASD closure get even more energy after it is closed.

Conclusion: ASD with moderate shunt requiring closure with surgery or a device delivered by catheter.