Week 5 Initial Post
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.
Murmurs
Systolic murmurs have only a few possible causes: blood flow across an outflow tract (pulmonary or aortic), a ventricular septal defect; atrioventricular valve regurgitation, or persistent patency of the arterial duct (ductus arteriosus) (Sackey, 2016). According to Sackey, (2016) A grade two/four murmurs are loud at the apex, grade four has a palpable thrill. In this scenario, the murmur is as a result of the ventricular septal defect. In ventricular septal defect, there is an opening in the septal wall between the ventricles; these are most common type of congenital heart defect accounting for 15%-20% of all defects (Huether, McCance 2017, p.660)
Diagnose and Treatment
Heart murmurs are common in children and often referred to a specialist for further evaluation. As Advanced Practice Nurse, my first intuition would be to evaluate further, if, after the evaluation, everything comes back right, at least it is better to be safe than sorry. I would order an echocardiogram and refer the patient to a pediatric cardiologist for further evaluation. Cardiac catheterization may be necessary depending on the result of the echocardiogram. Spontaneous closure of VSD is determined through a variety of methods; echocardiography, Doppler color flow imaging, angiography, auscultation, and cardiac catheterization, and can be proven by pathological evidence at necropsy (Jun et al. 2015). Surgical repair might also be necessary; Open-heart Surgery with cardiopulmonary bypass.
Genetics
Congenital heart disease is a multifactorial disorder associated with both genetic and environmental influences. Approximately 30% of congenital heart disease is thought to be related to genetic syndromes accompanied by extra-cardiac anomalies (Ko, 2015). Chromosomes 21 trisomy is common to VSD; Congenital heart disease occurs in 40-50% of patients with Down syndrome (Ko,2015).
The child in this scenario does not have any family history of the cardiac problem, and there is nothing in the assessment pointing to VSD except the auscultation of murmurs that is why it is imperative to investigate further for more information. The auscultation of heart murmur would give me a clue as to why a healthy child with no cardiac and family history has possible VSD. It is quite unfortunate when things like this happen but investigating further when something is not right is part of using the critical thinking skills.
References:
Jun, Z., Jong Mi, K., Guileyardo, J. M., & Roberts, W. C. (2015). A review of spontaneous
closure of ventricular septal defect. Baylor University Medical Center Proceedings, 28(4),
516-520.
Ko, J. M. (2015). Genetic Syndromes associated with Congenital Heart Disease. Korean
Circulation Journal, 45(5), 357–361. http://doi.org/10.4070/kcj.2015.45.5.357
Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology
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