NUR 607 Module 4 Focused Cardiac Exam Example

Focused Cardiovascular Assessment: A Dynamic Systolic Murmur at a Preparticipation Physical in a 17-Year-Old Athlete

[Student Name]

Southern New Hampshire University

NUR 607: Advanced Health Assessment

Module Four Focused Cardiac Exam

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Focused Cardiovascular Assessment: A Dynamic Systolic Murmur at a Preparticipation Physical in a 17-Year-Old Athlete

Most murmurs heard at sports physicals are innocent flow murmurs in healthy hearts. A few signal structural disease that can cause sudden death during exercise, and hypertrophic cardiomyopathy is among the most common of these in young American athletes (Maron, 2003). The preparticipation examination is often the only time a clinician listens to an adolescent's heart, so the write-up must show not only that a murmur was heard but how it behaved. This focused assessment documents a murmur that changes with maneuvers in a young athlete with a concerning family history and shows how those findings, recorded precisely, lead to a decision to hold clearance.

Subjective

Chief concern: "I need a physical to play soccer this fall."

History: J. is a 17-year-old high school senior who plays club and varsity soccer, training about 10 hours a week. He reports no chest pain or pressure with exercise, no fainting or near fainting, no palpitations and no shortness of breath out of proportion to effort. He has never been told he has a murmur or high blood pressure and has never been restricted from sports or had cardiac testing. He takes no medications or supplements, including stimulants or energy drinks, and denies anabolic steroid use.

Family history: his mother reports that her brother died suddenly at age 38 while jogging; no autopsy results are known. No known family members with cardiomyopathy, heart surgery before 50, pacemakers or implanted defibrillators, long QT syndrome or Marfan syndrome. Father, 50, has hypertension.

Review of systems: General: no fatigue or weight loss. Respiratory: no wheeze or cough with exercise. Neurologic: no dizziness on standing. Musculoskeletal: no joint laxity or recurrent dislocations.

Objective

Vital signs: blood pressure seated 118/70 mm Hg on the right and 120/72 mm Hg on the left, with an appropriately sized cuff; pulse 58 beats per minute and regular; height 180 cm; weight 72 kg.

General: well-appearing adolescent. No features of Marfan syndrome: arm span 178 cm, less than height; no pectus deformity, high-arched palate or lens problems reported; thumb and wrist signs negative.

Cardiovascular: jugular venous pressure not elevated. Carotid upstrokes brisk and equal, without delay. Apex beat palpable in its usual place on the left chest, not displaced, but sustained through most of systole rather than tapping. S1 normal; S2 physiologically split. A grade 2 of 6 midsystolic ejection murmur is loudest along the lower left edge of the sternum, without radiation to the carotids. No diastolic murmur, click, rub or gallop. Femoral pulses strong and simultaneous with radial pulses.

Dynamic maneuvers: the murmur increases to grade 3 of 6 when he moves from squatting to standing and increases during the strain phase of a Valsalva maneuver. It decreases to grade 1 of 6 when he squats from standing. Hand grip was not performed. Auscultation was repeated after each position change.

Respiratory: lungs clear bilaterally. Extremities: no edema or clubbing.

Interpreting the Maneuvers

Maneuvers help separate murmurs by how they respond to changes in ventricular filling. Standing from a squat and the strain phase of a Valsalva maneuver both reduce venous return and make the left ventricle smaller, which narrows the outflow tract in hypertrophic cardiomyopathy and makes that murmur louder. Most other systolic murmurs, including innocent flow murmurs and aortic stenosis, become softer when filling falls. Squatting does the opposite, increasing filling and softening a hypertrophic cardiomyopathy murmur. In a systematic review of the clinical examination, an increase in murmur intensity with Valsalva was among the more useful findings for identifying hypertrophic cardiomyopathy, although most of the evidence came from cardiologist examiners and agreement between observers on murmurs was only fair (Etchells, 1997). J.'s murmur behaves exactly as an outflow obstruction would, and his sustained apical impulse fits left ventricular hypertrophy.

The pertinent negatives matter as much as the positives. Equal blood pressures in both arms and femoral pulses that arrive with the radial pulses argue against coarctation of the aorta, a cause of hypertension and sudden death that a murmur alone can hide. The absence of a diastolic murmur and a normally split second sound make a significant atrial septal defect or aortic regurgitation less likely. The absence of Marfan features lowers concern for aortic dissection. Each of these negatives is written into the note so that the cardiologist can see what was considered and set aside, and so that the reason for referral is narrowed to the finding that remains unexplained.

Assessment

Systolic murmur that increases with maneuvers that reduce preload, in an asymptomatic 17-year-old athlete with a family history of sudden death before age 50. The AHA 14-element screening recommendations list a heart murmur and a family history of premature sudden death as findings that call for further evaluation before clearance (Maron et al., 2014). The leading concern is hypertrophic cardiomyopathy. The differential includes an innocent flow murmur, which is common but would be expected to soften on standing, a small ventricular septal defect and mitral valve prolapse with regurgitation, which can also lengthen on standing but is usually late systolic and accompanied by a click.

Plan

Clearance is deferred pending evaluation. Order a 12-lead electrocardiogram today and a transthoracic echocardiogram, and refer to pediatric or sports cardiology. Explain to J. and his mother that the murmur and family history need testing before he can play, that the most likely result is still reassuring and that the evaluation will be arranged within two weeks. Advise him to avoid competitive play and intense training until reviewed. Encourage his mother's side of the family to share any autopsy or cardiology records from her brother, and note that first-degree relatives of a person with hypertrophic cardiomyopathy may need screening if the diagnosis is confirmed.

Conclusion

A preparticipation physical is only as good as its documentation. Recording each element of the cardiovascular screen, describing the murmur fully and documenting how it changed with standing, straining and squatting turned an ordinary sports physical into a recognized risk. Precise notes let the cardiologist see exactly what prompted the referral.

References

Etchells, E. (1997). Does this patient have an abnormal systolic murmur? JAMA, 277(7), 564-571. https://doi.org/10.1001/jama.1997.03540310062036

Maron, B. J. (2003). Sudden death in young athletes. New England Journal of Medicine, 349(11), 1064-1075. https://doi.org/10.1056/NEJMra022783

Maron, B. J., Friedman, R. A., Kligfield, P., Levine, B. D., Viskin, S., Chaitman, B. R., Okin, P. M., Saul, J. P., Salberg, L., Van Hare, G. F., Soliman, E. Z., Chen, J., Matherne, G. P., Bolling, S. F., Mitten, M. J., Caplan, A., Balady, G. J., & Thompson, P. D. (2014). Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): A scientific statement from the American Heart Association and the American College of Cardiology. Circulation, 130(15), 1303-1334. https://doi.org/10.1161/CIR.0000000000000025