Pediatric Heart Sounds Michael E. McConnell with contributions by Alan Branigan Pediatric Heart Sounds 1 3 MichaelE.McConnell,MD EmoryUniversityandtheSibleyHeartCenter Cardiologyat52ExecutiveParkSouth Suite5200. Atlanta,GA30329 USA withcontributionsby AlanBranigan,MA,MEd Director,EducationalSupport EasternAreaHealthEducationCenter 2000VentureTowerDr. Greenville,NC27835-7224 USA ISBN978-1-84628-683-4 e-ISBN978-1-84628-684-1 DOI10.1007/978-1-84628-684-1 BritishLibraryCataloguinginPublicationData AcataloguerecordforthisbookisavailablefromtheBritishLibrary LibraryofCongressControlNumber:2008931524 #Springer-VerlagLondonLimited2008 Thesoftwarediskaccompanyingthisbookandallmaterialcontainedonitissuppliedwithoutany warrantyofanykind.Thepublisheracceptsnoliabilityforpersonalinjuryincurredthroughuseor misuseofthedisk. 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Productliability:Thepublishercangivenoguaranteeforinformationaboutdrugdosageand applicationthereofcontainedinthisbook.Ineveryindividualcasetherespectiveusermustcheck itsaccuracybyconsultingotherpharmaceuticalliterature. Printedonacid-freepaper SpringerScienceþBusinessMedia springer.com Preface v Preface vii Whyanotherbooktoteachauscultation?Isn’ttheuseofthestetho- scopea‘‘lostart’’,totallyunnecessaryintheageofechocardiography and‘‘handheld’’imaging‘‘stethoscopes’’?Theansweristhatthereis perhapsnootherphysicalexaminationskillthataphysicianmaking patientcaredecisionsmust havethatismoreimportant,evennow. If a patient complains of fever and a cough, a chest radiograph interpreted by someone else will either confirm or rule out the diagnosis of pneumonia, and a quick look in a textbook can tell the physician the next course to take. When a patient comes to the office with no complaints, and on auscultation has a soft systolic murmur,onlygoodphysicalexaminationskillswillallowtheexam- iner to reassure the patient that the murmur is non-pathologic. There is unfortunately ample evidence that auscultatory skills are very poorly taught to medical students and residents [1]. Research does show that intensive instruction, followed by reexamining patients with known lesions, will improve the diagnostic accuracy. Unfortunately, in busy practices, the ability of the learner to listen, discuss the findings with the preceptor, and to listen again is often lacking [2]. The inability to appreciate abnormalities of precordial activity, to critically listen to the first and second heart sounds, and todiscernthedifferencebetweenapathologicmurmurandafunc- tionaloneoftenleadstounnecessarytesting,andpotentiallyleadsto missed diagnoses. Thereareamplesourcestohelpimprovephysicalexamination skills, many written by the true great teachers of medicine. Yet, in spiteofthese,auscultationskillsarepoorlylearned.Withtheadvent of new ‘‘multimedia’’ technology, perhaps auscutation can be more effectively taught. Unfortunately, recent evidence with some multi- mediateachingtoolssuggeststhatthelearningisstillineffective[1]. TheCD-ROMthataccompaniesthistextusesanovel approach to educatethelearneraboutauscultationskills.Itisnotmeanttobean exhaustive ‘‘encyclopedia’’, listing every possible abnormal sound that the heart can make. The goal is to get the learner more comfortable using the stethoscope in an organized fashion, and once they have the organized system of auscultation, to improve theirabilitytotellpathologicfromnormalheartsounds.Thecardiac sounds on the CD-ROM were recorded from patients with the specific cardiac abnormalities listed, and the specific pathology was confirmed using echocardiography. The programmed nature viii Preface oftheCD-ROMforcesthelearnertocriticallyevaluateallaspectsof thecardiacexamination.Byplacingthefindingsinthespreadsheet, andgettingimmediatefeedbackoncorrectandincorrectresponses, the learner’sability to listen critically should improve. References 1. Mahnke CB, Nowalk A, Hofkosh D, Zuberbuhler JR, Law YM (2004)Comparisonoftwoeducationalinterventionsonpediatric residentauscultation skills. Pediatrics 113(5):1331–1335 2. Favrat B, Pecoud A, Jaussi A (2004) Teaching cardiac ausculta- tion to trainees in internal medicine and family practice: does it work?BMC Med Educ 4(1):5 Contents ix Contents xi 1 NormalHeartSounds.................................. 1 TheFirstHeartSound................................... 3 TheSecondHeartSound................................. 8 References............................................. 12 2 InnocentHeartMurmurs............................... 13 Introduction ........................................... 15 PeripheralPulmonaryFlowMurmurs....................... 15 Still’sMurmur.......................................... 19 TheAorticOutflowMurmur.............................. 24 References............................................. 25 3 AtrialSeptalDefects ................................... 27 Introduction ........................................... 29 Anatomy.............................................. 30 Inspection............................................. 32 Palpation.............................................. 32 Auscultation ........................................... 33 SubacuteBacterialEndocarditisProphylaxisRecommendations (SBE)................................................. 36 References............................................. 37 4 VentricularSeptalDefects .............................. 39 Incidence.............................................. 41 Anatomy.............................................. 41 Physiology............................................. 43 NaturalHistory......................................... 45 MedicalManagement .................................... 45 SurgicalOptions...................................... 46 PhysicalExamination.................................. 47 SmallMuscularVentricularSeptalDefects ................... 47 ModerateVentricularSeptalDefects........................ 48 LargeVentricularSeptalDefects ........................... 50 SubacuteBacterialEndocarditisProphylaxisRecommendations (SBE)................................................. 53 Summary.............................................. 53 References............................................. 53 5 PatentArterialDuct.................................... 57 Introduction ........................................... 59 Anatomy.............................................. 59 Physiology............................................. 60 xii Contents NaturalHistory......................................... 60 SurgicalOptions........................................ 61 Auscultation......................................... 61 SubacuteBacterialEndocarditisProphylaxisRecommendations (SBE)................................................. 62 References............................................. 63 6 AorticStenosis ........................................ 65 Introduction ........................................... 67 Anatomy.............................................. 67 Physiology............................................. 68 NaturalHistory......................................... 69 AuscultatoryFindings.................................... 69 SubacuteBacterialEndocarditisProphylaxisRecommendations (SBE)................................................. 71 Summary.............................................. 71 References............................................. 71 7 PulmonaryStenosis.................................... 73 Introduction ........................................... 75 Anatomy.............................................. 75 Physiology............................................. 76 NaturalHistory......................................... 79 Auscultatoryfindings .................................... 80 SubacuteBacterialEndocarditisProphylaxisRecommendations (SBE)................................................. 82 References............................................. 83 8 MitralValveInsufficiency............................... 85 Introduction ........................................... 87 Anatomy.............................................. 87 Physiology............................................. 89 NaturalHistory......................................... 89 SurgicalOptions........................................ 89 AuscultatoryFindings.................................... 90 Mitralvalveregurgitationfromacleftmitralvalve........... 90 Mitralvalveregurgitationfromaprolapsingmitralvalve...... 91 SubacuteBacterialEndocarditisProphylaxisRecommendations (SBE)................................................. 92 References............................................. 93 9 TetralogyofFallot..................................... 95 Incidence.............................................. 97 Anatomy.............................................. 97