I definitely heard a murmur

[Guest ral]

 

So I looked at the original title I posted for this thread.  It was uncalled for.  My apologies.

Twice in the past two months, I have made referrals to cards for murmurs.  First was a young twenties female in for allergies/URI. Murmur heard midsternal border.  Increases on inspiration.  I’m thinking maybe tricuspid regurge.  Make referral and discuss with her primary.  He has her in, and notes same murmur.  She goes to cards.  I read the note: regular rate and rhythm, no murmur.

Today I am clearing an elderly lady for surgery, and hear a 3/6 SEM RUSB.  Talk to her primary, then get her over to cardiology, so that she can be checked out to carry through with surgery.  Just read note: “bla...bla bla bla... no murmur”.

WTH??  I know a frikken murmur when I hear one.

[sas5814]

Some murmers can come and go... get loud and then get quiet. I feel your frustration. I have referred lots of folks who get to the specialist and they just say "nah". *sigh*

[LKPAC]

try ordering an echo.

[camoman1234]

I always order ECHO (we do them every Monday in-house) so they are easy for me to get them down and then send a referral based off the ECHO results. Much easier/quicker way of getting that patient in to cardio and you have more proof. 

[Joelseff]

Twice in the past two months, I have made referrals to cards for murmurs.  First was a young twenties female in for allergies/URI. Murmur heard midsternal border.  Increases on inspiration.  I’m thinking maybe tricuspid regurge.  Make referral and discuss with her primary.  He has her in, and notes same murmur.  She goes to cards.  I read the note: regular rate and rhythm, no murmur.

Today I am clearing an elderly lady for surgery, and hear a 3/6 SEM RUSB.  Talk to her primary, then get her over to cardiology, so that she can be checked out to carry through with surgery.  Just read note: “bla...bla bla bla... no murmur”.

WTH??  I know a frikken murmur when I hear one.

Hahah I think the same thing sometimes. Had more than a few murmurs heard with my amplified Littman 3200 that I sent to Cards and got back a NL report. Order a Echo. I think it goes for other specialists too. I actually had a perf'd tm pt I sent to ENT and the exam said "TMs intact bilaterally" then punted back to me. I looked at the pt again and had my SP look too and it was definitely perf'd. I am not sending pts to that ENT anymore.

 

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[MidwesternTexan]

It's just 'cause we're better diagnosticians and with the exams. ;-)

 

I too have done several pre op H&P's, heard a murmer- 'cept Cardi did too and got an Echo, etc.

My advice to you- keep doing exactly what you're doing, and don't lower your threshold for escalating things.

You know what you know

[ventana]

stop sending out when you can handle it in house......

 

 

yes some murmurs come an go - think high flow states - illness, pregnancy and the like bringing them on...

 

My murmur work up is simple, EKG and Echo - FIRST

Then only if something comes up do I refer out....

 

[Reality Check 2]

I never tell anyone who examines me up front that a murmur has been heard in the past and I have a negative echo. About 1/3 of folks hear it. Hydration, pulse rate, phase of the moon - whatever.... some hear it and others don’t. 

If they hear a murmur and ask - I tell them the history. 

Most of the local cards I work with hear the stuff I do. Guess I have been lucky.

I agree, keep listening, documenting and investigating. You are doing right by the patients. It will keep a patient out of trouble at least once.

[Guest ral]

Stress echo was part of the plan.  PCP said to give a ring to the cardiologists’ office, and kill two birds with one stone.  They have all the needed equipment at their clinic.   Works for me, and I am new to the area and practice, so still collecting contacts.  I am just confused as to how a 3/6 disappears in 30 minutes.

 

[GetMeOuttaThisMess]

Twice in the past two months, I have made referrals to cards for murmurs.  First was a young twenties female in for allergies/URI. Murmur heard midsternal border.  Increases on inspiration.  I’m thinking maybe tricuspid regurge.  Make referral and discuss with her primary.  He has her in, and notes same murmur.  She goes to cards.  I read the note: regular rate and rhythm, no murmur.

Today I am clearing an elderly lady for surgery, and hear a 3/6 SEM RUSB.  Talk to her primary, then get her over to cardiology, so that she can be checked out to carry through with surgery.  Just read note: “bla...bla bla bla... no murmur”.

WTH??  I know a frikken murmur when I hear one.

 

The pre-op clearance pt. is AS until proven otherwise. By chance did you check carotids (specifically right side)? If nothing else they failed to add to the profit margin by getting the echo. No way we’d let that out our doors in the late 80’s/early 90’s w/o an echo. You did right.

[lkth487]

In peds (especially babies), it's even worse b/c generally you don't order ECHOs yourself without cardiology.  So a lot of it is just arguing with the cardiologists.  Sometimes you end up being right, sometimes not.  But you do get to act smug when you end up being right :p.

[Guest ral]

Well, I must have been typing loudly.  I see they’ve added an echo and nuclear stress to the plan, for positive murmur on exam.  The PhysExam notes specifically state “No murmur”.  

GMOTM: some radiation upward but relatively quiet carotids.

[Reality Check 2]

One of my kids has a PFO - can only hear it when febrile. That's how it was found when he was a little guy.

The Peds Cards in my town will see anyone and everyone - they would rather rule out than argue over semantics or who heard what.  They are an amazing resource and follow everyone to adulthood and the beyond.  I feel very lucky to have them as a resource in our community.  

I have sent a few kids that turned out to be a nothing and they respectfully send notes explaining the possibilities and LOVE to educate. One looked at an EKG I faxed and calmly explained the leads were backwards. My jerk MA at the time argued that he did it right. Told him to do it again and start over - a nurse took over after he pouted (another story) - lo and behold - the leads were backwards - new EKG - voila - normal. 

Another trick I learned was to have a partner in my practice - someone I trust. If I walk in and say "Hey, will you listen in Room 3?" that person knows - I won't give any clues. But another set of ears and we both learn something.  He does the same thing back to me. Together we have found some strange stuff.  It also works with funny looking moles :) 

Cannot stress enough building those relationships you seem to be working on, Ral. Finding your advocates and supporters in specialties is priceless. 

[Gordon, PA-C]

19 hours ago, lkth487 said:

In peds (especially babies), it's even worse b/c generally you don't order ECHOs yourself without cardiology.  So a lot of it is just arguing with the cardiologists.  Sometimes you end up being right, sometimes not.  But you do get to act smug when you end up being right :p.

In peds this is done for a reason, the echo tech needs more information to go on so they can focus on the right windows.   They have a limited length of time to get good windows before the child gets too agitated/fussy and then there's no way they can see anything once the child gets annoyed.  So the echo tech needs to know what to prioritize.  Aorta, pulmonary vessels, heart wall thickness, etc.  

In adults it doesn't matter because you can yell at them to shut up and stop moving and take as long as you need to get good views from all the different angles you need.

 

 

[lkth487]

54 minutes ago, Gordon, PA-C said:

In peds this is done for a reason, the echo tech needs more information to go on so they can focus on the right windows.   They have a limited length of time to get good windows before the child gets too agitated/fussy and then there's no way they can see anything once the child gets annoyed.  So the echo tech needs to know what to prioritize.  Aorta, pulmonary vessels, heart wall thickness, etc.  

In adults it doesn't matter because you can yell at them to shut up and stop moving and take as long as you need to get good views from all the different angles you need.

 

 

Oh, yeah for sure. 

I've started to do ECHOs/US now (basic stuff) in the PICU/NICU emergently when necessary, and it's a lot harder than in adults!  I specifically picked a fellowship that prioritizes that, so hopefully I can get better at it.