Respond to at least two of your colleagues who selected a different factor than you, in one of the following ways:
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Share insights based on your own experience and additional research.
A 16-year-old male presents for a sports participation examination. He has no significant medical history and no family history suggestive of risk for premature cardiac death. The patient is examined while sitting slightly recumbent on the exam table and the advanced practice nurse appreciates a grade II/VI systolic murmur heard loudest at the apex of the heart. Other physical findings are within normal limits, the patient denies any cardiovascular symptoms, and a neuromuscular examination is within normal limits. He is cleared with no activity restriction. Later in the season he collapses on the field and dies.
Heart murmurs can be common in healthy infants, children, and adolescents. These murmurs are often innocent and result from normal patterns of blood flow through the heart. “Although most are not pathologic, a murmur may be the sole manifestation of serious heart disease” (Frank, J., Jacobe, K. 2011). If a murmur is detected, a thorough evaluation is needed.
In this scenario, I would most likely have referred this patient out to a pediatric cardiologist. I would be hesitant because he has no family history and exam is negative. Only reason I would like to send him to a pediatric cardiologist is because he is young, even though he has no signs of symptoms, I could be missing something. The cardiologist would be able to do a more in-depth examination. The cardiologist could order an echo, ECG, and chest X-Ray. This 16-year-old male has a high-grade murmur, which can be heard at the apex of the heart, which could suggest MVR or MVP or aortic stenosis. “Certain characteristics of the murmur may be considered red flags, prompting stronger consideration for structural heart disease. These include a holosystolic murmur, grade 3 or higher should warrant a referral” (Frank, J., Jacobe, K. 2011).
Genetics can play a role in cardiac murmurs. Mostly, murmurs are discovered when a child is just a few days old or younger than 6 months. Usually, there will be signs and symptoms present with genetic murmurs in newborns and young children. Sometimes, in the older child, there will be a murmur present that does not cause symptoms or problems, but other times these asymptomatic murmurs can be deadly. Family history is an important factor and can be helpful when diagnosis an older child with a murmur. If during the scenario the mother had stated a family history of cardiac issues, I would not hesitate to send this patient to a cardiologist.
Frank, J., Jacobe, K. (2011). Evaluation and Management of Heart Murmurs in Children. American Family
Physician. 1;84(7):793-800. Retrieved from https://www.aafp.org/afp/2011/1001/p793.html
Mayo Clinic. (2019). Heart Murmurs. Retrieved from https://www.mayoclinic.org/diseases-
Stanford Children’s Health. (2019). Heart Murmurs in Children. Retrieved from
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