Heart Auscultation Quiz
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10 year old with 10 days of fever, increased heart rate and bounding pulses. He looks tired and unwell. Normal past history regarding growth and development, no prior symptoms.
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7.1 S1 not audible
7.2 S2 not audible
7.3 Systolic ejection murmur, loud and harsh- likely at least 4/6
7.4 Early diastolic murmur, blowing
7.5 Aortic stenosis and insufficiency
Conclusion: This child has aortic stenosis with insufficiency, likely with a bicuspid aortic valve and with the fever may have infective endocarditis. The murmurs are not continuous but have a to and fro, “sawing wood” cadence. The heart rate is increased with the fever and the pulses are bounding due to diastolic runoff from the aorta with the valve incompetence. This lowers the diastolic pressure. The recording was made from the LSB since that is where the diastolic murmur is loudest with the backward flow from aorta to left ventricle. The systolic murmur is even louder over the RUSB or “aortic area”, with a thrill.
This is a dangerous situation as the valve may literally fall apart causing wide open regurgitation and instant heart failure as well as failure of coronary flow. If the child is stable a course of intravenous antibiotics is needed, with surgery on standby. Valve replacement is inevitable.
Your assessment of this child’s heart:Correct
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