Heart Auscultation Quiz

Answers

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.