Heart Auscultation Quiz

Answers

8.1 S1 is normal
8.2 S2 is single as expected at the apex (P2 cannot be heard normally there)
8.3 Systole: Ejection click
8.4 Diastole: Silent
8.5 Bicuspid aortic valve

Conclusion: In early systole there is a discrete sound (not a murmur as murmurs have duration) which is an ejection click. These are always abnormal. The clicks are usually best heard at the apex or even below the left costal margin. Clicks are more likely to be heard than split S1 as they are slightly delayed after S1. They can be due to bicuspid aortic valves, or a dilated aorta in patients with connective tissue abnormalities such as Marfan syndrome. As he has normal body habitus the bicuspid aortic valve is most likely.

At present he has no stenosis or insufficiency but these can develop over several years or decades in over 50% of cases. A family history may reveal others with the same problem and a discussion with the parents about screening the family with echocardiography is advisable. He requires an echo to visualize the valve and evaluate the aortic root which is dilated in some of these patients with bicuspid valves. No physical restriction is indicated at this stage but as the valve may progress to stenosis or insufficiency or aneurysmal dilation of the aortic root, echo is indicated every few years as growth occurs, and also in adulthood.