Evaluating Pediatric Cardiac Murmurs: Keisha’s Case
Keisha has come in for her annual well-child visit. Keisha enjoys preschool, she has been a healthy child, and she is at the 50% for height and weight. On exam, you note a Grade III/VI, mid-systolic murmur, heard best in the left sternal border.
- What additional information should the APRN know about Keisha?
- What tests should the APRN order?,
- What should the APRN specifically include in the cardiac physical examination?
- How should the APRN approach referrals?
Additional Information that the APRN has to know about Keisha
The APRN should inquire about Keisha’s past medical history and ask whether she has had any signs and symptoms of the heart like fatigue, breathing difficulties, cyanosis, low weight gain or syncope. Additionally, a complete evaluation of family history on heart disease, cardiac-related death information and genetic disorders must be established before diagnosis. A full patient medical history including recurring respiratory infections, feeding troubles or reduced exercise tolerance must be recorded because it reveals the significance of the heart murmur.
Evaluating Pediatric Cardiac Murmurs: Keisha’s Case
Tests to Order
The APRN should request for an electrocardiogram (ECG) to check for any conduction disturbances or signs of the ventricular hypertrophy that implies structural heart disease. Chest X-ray should also be used to assess the size of the heart and pulmonary vasculature for the markers of increased cardiac demand. If the murmur is suspected to be pathological, then an echo should be arranged to give further views of the cardiac structures and their performance. If there is still doubt, the child may be referred to a pediatric cardiologist for further diagnostic studies.
Cardiac Physical Examination
The APRN should examine the location and intensity of the murmur. Its pitch and the nature of radiation, if it is position related or activity related. In performing an inspection of the precordium, examination for thrills, heaves, or abnormal impulses should be done. There should be equal strength and number on the right and left sides. Femoral should be checked to eliminate coarctation of aorta. Other examination findings that should be assessed include capillary refill time. Blood pressure in the four limbs, and signs of cyanosis or clubbing. Therefore, more assessment should be done to check for an S3 or S4 gallop. Click or changes in the murmur with the Valsalva maneuver.