Cardiac Case: 18-year-old Woman with Murmur

by Joseph Alpert, MD

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    00:01 This woman recently arrived in the US and she was brought to the office for a physical exam.

    00:06 She'd been seen at an urgent care clinic for a minor dermatologic complaint and the nurse clinician there said she heard a murmur and that she should see a cardiologist.

    00:15 She denies any cardiovascular symptoms currently or in the past, says she's a perfectly healthy 18-year-old.

    00:22 The blood pressure's a little low at 86/56 mmHg but on the other hand, not uncommon in a healthy young woman presumably due to lots of estrogen effect.

    00:31 Her heart rate's fine at 68, jugular vein is not distended, the lungs are clear, and the cardiac exam demonstrates a quite impressive holosystolic murmur heard directly over the sternum, directly over the breast bone.

    00:45 So, let's listen to that murmur.

    00:47 First, let's do the heart sound, lub-dub, lub-dub, and here's the murmur, lub-whoo-dub, lub-whoo-dub, lub-whoo-dub So, this is a kind of harsh murmur perhaps sometimes even harsher than I did it and it's heard over the sternum and it is very suggestive of a ventricular septal defect and the rest of her exam is completely normal.

    01:10 She has normal blood test and her chest X-ray is unremarkable.

    01:14 Now remember, when we looked at a case of atrial septal defect with a left to right shunt, we saw lots of blood flowing into the lungs from the left to right shunt.

    01:23 Clearly, even though we think this is a VSD, we don't see a lot of increased blood flow so, we're expecting it's going to be a small VSD.

    01:31 So, the critical thing here in the history in physical: a little bit of hypotension might be due just to her young age and female status, the cardiac exams we've talked about suggests a murmur of ventricular septal defect, and of course, we do an echocardiogram. And here we see a little tiny VSD.

    01:52 That little green mark in the doppler shows a small left to right shunt.

    01:58 You'll see the left ventricles on the right and you'll see the right ventricles on the left and there's a little hole in the septum and a very small green flow across the septum.

    02:08 So, this lady does have, just what we expected from physical exam and chest X-ray and so forth, that this lady has a very small VSD.

    02:16 She has a very small amount of left to right shunting through the VSD and the amount of shunt flow is quite small, the patient's very unlikely to develop pulmonary vascular disease and pulmonary hypertension and often these are left untreated except for prophylactic antibiotics at the time of dental work or other surgery because there's always a chance for endocarditis forming on that.

    02:39 So, she just needs regular cardiac check-ups, prophylactic antibiotics as we mentioned for dental work and other surgical interventions and no restrictions on activity, and reassurance that she's going to do very, very well.

    02:51 This is not a major drain on the heart function.

    About the Lecture

    The lecture Cardiac Case: 18-year-old Woman with Murmur by Joseph Alpert, MD is from the course Cardiovascular Cases.

    Included Quiz Questions

    1. Holosystolic murmur heard best over the sternum
    2. Holosystolic murmur heard best over the mitral area
    3. Continuous murmur heard best at the left infraclavicular area
    4. Crescendo–decrescendo systolic murmur heard best at the right second intercostal space
    5. Late systolic crescendo murmur with mid-systolic click
    1. Therapy is not required at this point in time.
    2. Avoiding volume depletion
    3. Avoiding exercise
    4. Referral for cardiac surgery
    5. Antibiotic prophylaxis prior to dental work

    Author of lecture Cardiac Case: 18-year-old Woman with Murmur

     Joseph Alpert, MD

    Joseph Alpert, MD

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