Discerning the pathology of a heart murmur.
But listening for the absence or presence of such sounds isn't the only thing pediatricians need to keep in mind when they try to make this distinction. It's also important for them to thoroughly examine children in a fully resting state--not after exercise--and while patients are standing, as well as lying on their back, said Dr. Lutin, director of the pediatric cardiac diagnostic laboratories at the Medical College of Georgia in Augusta.
Furthermore, a series of exams--rather than just one, especially if a child is feverish--will help distinguish innocent from pathologic murmurs, he said.
"If a murmur comes and goes" during multiple exams, said Dr. Lutin, "it's most likely to be innocent." A murmur also is probably benign if it is abolished or greatly reduced while the child is standing, he added.
"Physical exam and history are the most important parts of evaluation of a child with heart murmur," Dr. Lutin said.
Assessments in the cardiac portion of an exam should include inspection (visible cardiac impulses on the precordium are sometimes a bad sign), palpation, and auscultation, he said. During these steps, "we do everything we can to try to get the kid's heart rate as slow as possible--to have a relaxed comfortable patient in our office."
In palpation, he feels for left-ventricle and right-ventricle impulses as well as thrills at the lower-left, upper-left, and upper-right sternal borders and the suprasternal notch. In auscultation, he notes the location of the first and second heart sounds ($1 and $2), listens for $2 splitting, and assesses the pulmonic second heart sound (P2). He also listens for clicks. (See box.)
The patient's history is important because it may provide helpful clues, Dr. Lutin explained. (See box.) For example, proximal muscle development often is delayed in an infant with a significant cardiac problem, so the child might not walk, sit up, or roll over at the usual age.
A warning sign in older children is a self-imposed limitation on activity and exercise, which is their way of compensating. To find out if that's happening, "I always ask a parent this question: Does [your child] keep up with you at the mall?" he said.
Relying on sophisticated tests and equipment might seem like the best way to detect pathologic murmurs, but the stethoscope is still the most important piece of diagnostic equipment, Dr. Lutin said.
He performs ECG on only about 8% of patients newly diagnosed with a murmur, and doesn't use it as a substitute for a thorough physical exam.
"No imaging study, machinery, or diagnostic test replaces the eyes, hands, spirit, and brain of the clinician," he said.
History for Children With a Murmur * Prenatal risk factors and teratogens, including alcohol. * Early growth and development (motor milestones). * Feeding pattern (for infants). * Time and clinical setting when murmur was first noted. * Activity and exercise tolerance (child may self-limit). * Respiratory symptoms, especially wheezing and recurrent problems. * Orthopnea, dyspnea, diaphoresis, cyanosis. * Family history of congenital heart disease, syndromology, or sudden death. Signs of Innocent vs. Pathologic Heart Murmurs Murmur Characteristic Innocent Pathologic Quality Vibratory Harsh Duration Short Variable Location Variable Variable Pitch Low- or midfre: uency Variable Radiation Along left sternal border, With flow not to the back Click, S3, or S4 No Variable Timing Systolic Variable Source: Dr. Lutin
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|Title Annotation:||Clinical Rounds|
|Date:||Feb 1, 2006|
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