Case study 1 - Screening Adolescent for Heart Risk

Case study 1 - Screening Adolescent for Heart Risk

Patient Name: Chris Brooker, Age 15, male

Height 5' 11"" Weight 178 BP: 115/78 P: 78 RR: 15/min

Chief complaint/reason for office visit: Pre-participation sports examination for basketball season

PMH: (Bulleted format)

� Mild, intermittent asthma since age 8; uses Albuterol as needed for wheezing and before playing sports. 2 puffs before start of exercise

� sometimes get short of breath with exercise, but not more than his teammates

� once felt like he was going to pass out when exercising, but thinks it was due to

dehydration and fatigue because it was during the Hot summer

He wants to play on the city league team. Has been playing on the team since grade school. He has mild, intermittent asthma and uses his Albuterol as needed for wheezing and before playing sports. On history he reports that he sometimes get short of breath with exercise, but not more than his teammates. He also says he once felt like he was going to pass out when exercising, but because it was during the hot summer, he thinks it was due to dehydration and fatigue. He is otherwise well

Family History

� negative for unexplained sudden deaths in anyone under 50 years

� Family Hx: DM - MGM; Pat GF: HTN; Pat GM: Breast CA

ROS

� Not documented - no pertinent positives or negatives

� HEENT - normal - wears glasses for distance vision since age 5; wears contacts

since age 12

� Card/Resp - no complaints

� GI - nausea occasional after

� GU - deny dysuria, frequency

� Surgeries: Tonsillectomy age 7

� NKDA

� Meds: None

Physical examination

� normal findings for all systems, except:

� Cardiac: new soft systolic ejection murmur [never heard before and it is not been documented elsewhere by others in the electronic medical record.

� What is the best way to screen adolescents to exclude those at risk of sudden cardiac death from athletic participation?

� In the U.S., the American Heart Association has not recommended the use of the 12- lead EKGs as a screening tool for athletic pre-participation. This is in contrast to other countries, such as Italy and Japan, which have been screening with EKGs for more than 20 years and report data that suggest a decrease in mortality rates from SCD in athletes as a result. Recently, the International Olympic Committee and European Society of Cardiology have recommended the use of the 12-lead EKG as a screen for athletic participation. The AHA has expressed concern about the high false-positive rate of mass EKG screening , as well as the practical implementation and cost-effectiveness of a mass EKG screening program.

In practice, what should the clinician do?

Certain locales, whether as part of a research protocol or through advocacy work, have been able to implement mass-participation EKG screening and place AEDs in high- school athletic venues.

Pay attention to the AHA 12-point screening recommendations and any concerns that arise should prompt further cardiac evaluation."

First case: Screening adolescent for heart risk

 

 Patient Profile:

 

 Name: Chris Brooker

 Age: 15

 Height: 5' 11"

 Weight: 178 lbs

 BP: 115/78 mmHg

 P: 78 bpm

 RR: 15/min

 Chief Complaint: Examination for pre participation in basketball for the next season

 Past Medical History (PMH):

 

 Mild, episodic asthma (only uses Albuterol inhaler on an as needed basis).

 Dyspnoea on exertion (as with teammates)

 A history of near-syncope in hot weather, which is ascribed to dehydration and fatigue.

 Family History:

 

 Nonsignificant for unexplained sudden death in persons below fifty years.

 Diabetes Mellitus (maternal grandmother)

 Hypertension (paternal grandfather)

 Breast Cancer (paternal grandmother)

 Review of Systems (ROS):

 

 HEENT: None; has eyesight and wears glasses as well as contact lenses.

 Cardiovascular/Respiratory: No complaints

 Gastrointestinal: Occasional nausea

 Genitourinary: The patient does not complaint of having dysuria or frequency

 Surgical History: Adenoidectomy at age 5 and Tonsillectomy at age 7

 Medications: None

 Allergies: NKDA

 Physical Examination Findings:

 

 Otherwise the physical examination was entirely normal apart from a new softer systolic ejection murmur.

 Questions and Recommendations:

 

 1. Best Way to Screen Adolescents to Exclude Those at Risk of Sudden Cardiac Death (SCD):Best Way to Screen Adolescents to Exclude Those at Risk of Sudden Cardiac Death (SCD):

 

 The best way to screen adolescents for SCD risk is by taking a detailed history and examination of the patient, as well as the family history, and if necessary, more diagnostic procedures. The American Heart Association (AHA) recommends a 12-point screening approach, which includes:The American Heart Association (AHA) recommends a 12-point screening approach, which includes:

 

 History of the patient and the family history

 Cooled emphasis on the cardiovascular and respiratory systems

 Recommendation of fuher cardiac examination if any abnormalities are detected.

 2. In practice, what should the clinician do?

 

 Follow AHA Recommendations: Begin with history and physical examination as outlined by the AHA. See if the new systolic ejection murmur needs any more evaluation.

 Evaluate Further: However, since Chris has a new murmur and has had some near syncope he may need further assessments. The only concern that the AHA has with mass screening is that it is expensive and are prone to false positives; thus, it is only recommendable in localized or high risk areas. If there are any questions regarding the possible presence of pre-existing cardiac conditions it is best to consult a cardiologist.

 Consider Local Practices: In the areas where the mass EKG screening and AED installations are provided, follow the recommendations if possible. In research contexts, or with particular programmes, further assessment can be useful.

 Rationale:

 

 1. Cardiac Evaluation: New onset systolic ejection murmur and history of near syncope are signs that require follow up due to possibility of having some cardiac origin. While many ejection murmurs in adolescents are innocent, a new finding should be further assessed to exclude more important disease.

 

 2. Utilization of EKGs: The AHA opines that mass EKG screening is not advisable because of high false-positive results; however, it is recommended that guidelines and protocols of the local region be followed when they are evidence-based and proven to work. Such measures can be fairly useful in the high risk or research environments.

 

 References:

 

 American Heart Association. (n. d. ). Recommendations for Preparticipation Screening. [Link]

 International Olympic Committee. (n. d. ). Cardiovascular Screening in Athletes. [Link]

 European Society of Cardiology. (n. d. ). Guidelines on Cardiovascular Screening. [Link]