Wednesday, October 25, 2006

Loose lips....

used to sink ships apparently. Now they upset grannies. Or one Granny in particular.

"?" I hear you ask so eloquently.

Allow me to explain.

Josh is a mate of mine. He's six now. When he was eighteen months old he had a "turn". He went all clammy and pale and fell over. Mum and Granny didn't think much about it at the time because it was over in a few seconds and he was right as 3.6p (Ninepence in Old Money) in no time. Then, a few months ago he started having "turns" at school. Just one at first (well obviously....) but the next one a month or so after that, then two more in a week. Since Mum was being called out of work on each such occasion both she, and the nice school secretary who had to accommodate Josh in her office (while she fretted in case he "went off on one" before mum came to collect him), were concerned enough to ask for a paediatric referral.

Josh remained the picture of rude good health throughout this time, ate well, grew and developed normally, and other than his occasional "turns", romped about with typical six-year-old vim and vitality. Still a paediatric referral seemed like a good plan, so that's what we arranged.

He came back to see me this week after a plethora of normal tests. The Consultant, a very good and eminently trustworthy opinion, is happy that his turns are not serious and need no further investigation. Granny however is not so sure. The thing is, the nice smart young Doc who saw her with Josh in the clinic told her he could hear a "murmur" that was probably the cause of his turns. His letter says the same, though it goes on to point out that the murmur had gone when the Consultant listened, and that he had explained to Granny that this could happen to "murmurs".

Well, call me old fashioned, but murmurs of a severity sufficient to cause "turns" shouldn't really do that. Indeed they should have much more of an impact on growth and development before the age of six, and probably have been present if not at birth then very soon after.

Now I must have listened to Joshes chest a couple of dozen times down the years and I've never heard a murmur (and still didn't this week as it happens). I know I've listened to a lot of Motorhead and the like down the years, but I can still hear the dropping of a pin at several dozen paces, so I like to think I might have spotted such a thing before now. Likewise I am sure the Consultant has heard a few murmurs in his time, what with being a paediatrician and all, but the nice young Doc in the Pressed White Coat of Diagnostic Loveliness has pronounced, and so now Josh has a "murmur".

For now, the Consultant and I have persuaded Mum that he is fine and no more tests are needed, but I can tell that Granny is not so sure. Which is a shame, because after further discussion with Mum and Josh this week it seems highly likely that his "turns" are actually simple faints, caused by reflex drops in blood pressure when he first leaps up to charge about after being confined at his desk for too long, of after getting up from sprawling about like all six year olds are occasionally wont to do.

Some folk really are just a bit more fainty than others and we don't have to make them all ill. And some heart sounds are just sounds and not murmurs.

8 comments:

Anonymous said...

Funny you should write this..my oldest was at the GP this week and all of a sudden he has a 'murmur'...maybe - it does run in the family..but still - never seen a more active kid in my life.

Still - we'll do as told and have him back in the rooms for a check-up in 6 months. You never know.

Anonymous said...

what sort of murmur did superdoc suddenly think that this 6 yo had suddenly developed?? Or was such an opinion not necessary?

Shinga said...

That must be tricky - there have been several studies that show that when somebody has a diagnosis like cardiac murmur, even when it is ruled out by others, the family tend to dissuade the patient from exercise etc., 'just in case'.

If the mother is a little bit unsure, it is difficult to know what it would take to make her fully confident (just how many 'negative' tests and consultations?). I hope that she doesn't start to restrict the little boy's activities as that might have an impact on his future CV health. V. tricky but obviously in a day's work for the GP who must have studied a module in family of the patient diplomacy.

Regards - Shinga

Felix Kasza said...

9d old money? I thought that until that useless decimalisation -- and I call it that despite having grown up and lived in metric coluntries (Austria, Luxembourg, etc.) for forty out of my forty-two years -- a pound sterling was equal to twenty shillings, each of which was equal to twelve pence .... If this recollection is not just a sign of my becoming a senile old coot, then 9d[old] == 9/240ths of a pound sterling == 0.0375 pounds == 3.75d[new]. Or am I completely off my rocker?

I think, Doctor, that your mind has been permanently warped by NHS payment scales, and that you subconsciously anticipate the next cut. :-)

Cheers,
Felix.

Doctor Jest said...

wendz-- sorry to hear that. I suspect at six months the thing will have gone. So many "flow noises" (the sounds made by normal blood flow) can mimic "murmurs". Specially if the child concerned has a fever or has been stressed / active immediately before the chest is listened to. Do keep us all posted.

anon-- no opinion was vouchsafed. And since neither the boss nor I could hear any abnormality we are taking it that none is needed.

shinga-- heh! They'd have to tie Josh down Gulliver-like to slow him down. Mum is in fact quite ok. It's Granny that remains unconvinced.

Felix- thanks for stopping by to correct my maths. Pardon me for enquiring, but do you manage to get out much ;-)

Mr Angry said...

My then 6 month old nephew was referred to a specialist after the GP thought he heard a murmur during a routine check-up.

That referral took several weeks to come through, and so it was a difficult time for my sister as he showed no outward signs of illness at all.

At the referral I understand they said it was very minor and he will probably 'grow out of it'. Not the most convincing medical advice ever given, but completely correct as I understand.

Unfortunately, anything to do with the heart, no matter how minor, is blown out of all proportion. Especially in the young.

Doctor Jest said...

angry-- an emotive area the heart to be sure. These days I have a rule that I won't even mention the word murmur until I have heard it at least twice. If I think I have found one I will always ask mum to come back for "a checkup" in two or three days. More often than not the "murmur" will have gone in the interim. Even the ones that don't are almost always entirely innocent, but as you say, "wait and see" sounds like pretty poor advice at first blush.... still it's generally all we have.

Alison Cummins said...

I remember my pediatrician telling my mother that I had a little murmer when I was six. Even now I have a strange heartbeat apparently — my doctor stares at me and says “don’t you feel those extra beats?” and of course I have no idea what she means because my heart has never beat any other way. I had some tests to rule out the sort of murmer that means I need to take antibiotics when I have my teeth cleaned, but apparently it’s not that. Whatever. I get dizzy sometimes, and I get out of breath when I hike uphill, but my sister has the same murmer and she runs marathons and runs up hills. So I figure my issues are just being out of shape. I don’t think about the murmer at all: it means nothing to me.

So... if I had a kid with a murmer I would just think “oh, just like me” and not worry about it. My guess is that people who become frantic about the notion of something wrong with a child’s heart — something that on the face of it would certainly seem to be something to be frantic about — don’t have the benefit of experience of knowing it’s banal.

It must be hard to convey that certainty without appearing to be flip — to be unconcerned about the murmer without seeming unconcerned about the child.