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Loading ...My previous post on the physical exam of the early precursor of the adult patient (the baby) dealt with the northern section. We now come to the heart exam.
Holes
As a connoisseur of the infant, I relish each opportunity to examine an infant. There is, however, a weight of responsibility that accompanies this wonderful experience; I am either the first, or one of the first to examine this child. I have nobody’s previous exam to rely on. If there is something to find, I must be the one to find it.
Nowhere is that responsibility more clear than in the exam of the heart. While good prenatal ultrasound has lowered the chance of an unexpected major cardiac problem, surprises can still happen – sometimes big surprises.
The transition from getting oxygen from mom to getting it from the air is a major one. Not only does blood need to start going to the lungs instead of the umbilical cord, detours around the lung need to be closed. To redirect bloodflow, the body doesn’t send out little bitty guys in orange vests, it uses our old pal physiology to do the job. Air in the lungs causes changes that close off these detours (like those little sawhorses with the flashing lights).
Sometimes, however, these detours are not completely closed off, resulting in two problems: patent foramen ovale (PFO) and patent ductus arteriosis (PDA). PFO is a small hole in the atria of the heart, and is normally very difficult to pick up on exam. Some have associated a PFO in adulthood with decompression sickness and migraine headaches, but the real significance of a PFO is debatable.
PDA is a term that can get confusing, as it can mean many things, including:
Patent Ductus Arteriosis- Public Display of Affection
- Personal Digital Assistant
- Particularly Dull Accountant
Astute readers of this blog will note that a PDA with a PDA could be using his PDA and be disgusted by PDA.
Now there’s an educational nugget!
Seriously, a PDA (the first type) can often be heard on exam as a murmur that is often described as “machine-like.” Since there are many types of machines, this can confuse medical students who may be listening for a deep voice saying “I am Opimus Prime.” It is not like that kind of machine, but instead a harsh, high-pitched murmur heard in the middle of the chest (I heard one a few weeks ago). If left untreated, a PDA can eventually cause heart failure or high blood pressure in the arteries to the lungs.
If left untreated, the fourth type of PDA can inflict pain on thousands.
Some holes in the newborn heart happen because of incomplete development of the walls between the chambers. There are two holes that can show themselves during the heart exam: the Vetricular Septal Defect (VSD) and Atrial Septal Defect (ASD).
Of the two, the VSD is far more significant. The higher pressure in the ventricles (pumping chambers) can push a large amount of blood through the hole. Paradoxically, the larger the hole, the softer the murmur. Large VSD’s can cause heart failure and generally present as an infant in respiratory distress. Smaller VSD’s cause a harsh murmur heard on the lower part of the infant’s chest. Larger VSD’s need to be closed surgically, while smaller ones can either close on their own or are small enough to not cause harm – even if persisting into adulthood.
The ASD is more subtle, and generally does not cause immediate harm. The murmur from an ASD is not caused by blood flowing through the hole, but instead an increase in blood going across the pulmonary valve. Left untreated, a large ASD can cause heart failure later in life. Sometimes the first presentation of an ASD is an adult having a stroke when a blood clot passes from the lower body to the brain through the defect (it would otherwise go to the lungs).
Other Heart Stuff
There are many other ways in which a newborn heart can be abnormal, but I am not going to discuss that in this post (it gets too technical). Let me just say that the advances in prenatal ultrasound have made the job of the pediatrician much less scary in this realm.
The rest of the heart exam is generally straightforward. You don’t have to listen for mysterious gallops or rubs in normal infants (see my previous posts on the heart exam for my thoughts on these sounds). The main challenge in the heart exam is to pick out the heart sounds from the background noise of a typical infant. They breathe quickly and sometimes very loudly, and they also cry and scream (in case you hadn’t noticed).
As a child gets older, the heart exam gets less exciting, although you still can’t be complacent. I once had a child who was just “acting sick” according to the parents. When I did an exam, everything checked out OK until I put my stethoscope to the heart. It was going at a rate over 200. The child was in a very fast heart rhythm called Supraventricular Tachycardia (SVT).
Never let down your guard, and never dismiss parents’ intuition.
Next, we take a journey even further south.
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I also had SVT and had my heart rate was clocked at 220. I wasn’t diagnosed until I was 19, but I always had it at various times growing up. It was typically dismissed as panic attacks (which naturally came after my SVT episodes) but I finally was recommended to a good cardiologist. One ablation later, and I’m fine. Scary stuff though, especially for a teenager.
an informative yet easy-to-understand post, as always!
In February of this year my husband had a cough which would not go away. Over the course of three weeks he went to three different physicians – each physician listened to his heart and lungs and claimed he simply had a cold. Two days after the last doctor visit and worried about my husband’s increasingly deteriorating condition, I talked him into going to my primary care physician. After listening to his heart for 30 seconds she scheduled him for an immediate chest xray and echo as she didn’t like how his lungs weren’t filling all the way with air, nor the loud murmur. Ten days later, he was on the table undergoing OHS to replace his mitral valve and repair the tricuspid valve; both of which were regurgitating at 70%.
We were shocked that three physicians could not hear what one doctor could. After discussing the case with a friend who is a physician, his immediate thought was that the cause was due to the type of stethoscope the other doctors were using. His oncology practice began to purchase high-end stethoscopes (NOT the ones with electronics) for hospital nursing staff because the less expensive ones they were using “were no better than what you get out of a Fisher Price doctor’s kit”.
I thoroughly enjoy your Physical Exam primers but thought you may want to include a mention under “Listening Devices” that with something so important as a stethoscope, you get what you pay for.
Holly: Many people are diagnosed with anxiety, only to be found later to have SVT.
Anna: My suspicion is that it was the ears, not the scopes. If you don’t slow down and really listen, you will miss things. My partner had an electronic stethoscope and it was too sensitive. He heard murmurs and bruits that were not there. I have a mid-range scope that does fine for me.
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