CVS- PED Flashcards by Maria Hazel Quiban

The examination of the heart and the vascular systems in infants and children is similar to that in adults. T or F

True

How well did you know this?

Not at all

Perfectly

To make the examination easier and more productive, a good clinician must recognize:

the fear/s of their patient
their inability to cooperate
(in many instances), their desire to play

How well did you know this?

Not at all

Perfectly

USE YOUR KNOWLEDGE OF THE DEVELOPMENTAL STAGE OF EACH CHILD

A ____________may be easiest to examine while standing or sitting on mother’s lap, facing her shoulder, or being held

2 yr old

How well did you know this?

Not at all

Perfectly

USE YOUR KNOWLEDGE OF THE DEVELOPMENTAL STAGE OF EACH CHILD

Give young children___________they cannot figure out how to drop the objectà no free hand to push you away

something t-o hold in each handà

How well did you know this?

Not at all

Perfectly

__________-to small childrenà will hold their attention à they may forget your examining them

Endless chatter

How well did you know this?

Not at all

Perfectly

USE YOUR KNOWLEDGE OF THE DEVELOPMENTAL STAGE OF EACH CHILD

Let children move the stethoscope themselves, going back to listen properly. true or false

True

How well did you know this?

Not at all

Perfectly

General abnormalities may suggest_____________-, as exemplified by Down syndrome or Turner’s syndrome

** increased likelihood of congenital cardiac disease**

How well did you know this?

Not at all

Perfectly

Around age________

Measure blood pressure in both arms and one leg at one time around this age
This is to check for possible _____________

Thereafter, the right arm blood pressure needs to be measured.

3 to 4

*coarctation of the aorta

How well did you know this?

Not at all

Perfectly

*in_______________, the blood pressure is lower in the legs than in the arms

coarctation of the aorta

How well did you know this?

Not at all

Perfectly

_____________children often have benign murmurs.

Preschool and school-‐aged

How well did you know this?

Not at all

Perfectly

Most common
Grade I-II/VI
Musical and vibratory
Early and midsystolic murmur with multiple overtones
Located over the mid or lower left sternal border
CAN also be heard over the carotid arteries

Still’s murmur

How well did you know this?

Not at all

Perfectly

__________- à disappearance of the precordial murmur

Carotid artery compression

How well did you know this?

Not at all

Perfectly

This murmur may be extremely variable and may be accentuated when cardiac output is increased, as occurs with__________________

Note: The murmur will diminish as the child goes from supine to sitting to standing

fever or exercise.

How well did you know this?

Not at all

Perfectly

Usually heard in preschool and school-aged children
Soft, hollow, continuous sound
Louder in diastole
Heard just below the right clavicle
Can be completely eliminated by maneuvers that affect venous return (lying supine, changing head position, jugular venous compression)
Same quality as breath sounds (frequently overlooked)

Venous hum

How well did you know this?

Not at all

Perfectly

Murmur heard in the carotid area or just above the clavicles
Early and midsystolic
Slightly harsh quality
Louder on the left
May be heard alone or in combination with the Still’s murmur
May be completely eradicated by carotid artery compression.

Carotid bruit

How well did you know this?

Not at all

Perfectly

*Among young children, murmurs without the recognizable features of the three common benign murmurs may_______– and should be evaluated thoroughly by pediatric cardiologists

signify underlying heart disease

How well did you know this?

Not at all

Perfectly

Pathologic murmurs that signify
cardiac disease can first appear
_______________
Examples include aortic stenosis
and mitral valve disease.

after infancy and during childhood.

How well did you know this?

Not at all

Perfectly

The murmur heard in
the carotid area or just
above the clavicles is
known as a ______________

It is early and
midsystolic, with a
slightly harsh quality. It
is usually louder on the
leftandmay be heard
aloneor in combination with the Still’s murmur. It may be completely
eradicated by carotid artery compression.

carotid
bruit.

How well did you know this?

Not at all

Perfectly

Location and Characteristics of Benign Heart Murmurs in Children*

How well did you know this?

Not at all

Perfectly

Preschool or early
school age

description:

Grade I–II/VI, musical, vibratory
Multiple overtones
Early and midsystolic
Mid/lower left sternal border
Frequently also a carotid bruit

Still’s murmur

How well did you know this?

Not at all

Perfectly

Preschool or early
school age

Venous hum

Soft, hollow, continuous
Louder in diastole
Under clavicle
Can be eliminated by maneuvers

Venous hum

How well did you know this?

Not at all

Perfectly

Preschool and later

Early and midsystolic
Usually louder on left
Eliminated by carotid compression

Carotid bruit

How well did you know this?

Not at all

Perfectly

Older child, adolescence and later

Grade I–II/VI soft, non-harsh
Ejection in timing
Upper left sternal border
Normal P2

Pulmonary flow murmur

How well did you know this?

Not at all

Perfectly

The_____________is a grade I–II/VI soft, non-harsh
murmur with the timing characteristics of an ejection murmur, beginning
after the** first sound and ending before the second sound** but without the
marked crescendo–decrescendo quality of an organic ejection murmur.

If you hear this murmur,** evaluate whether the pulmonary closure sound is of
normal intensity** and** whether splitting of the second heart sound is eliminated**
during expiration.

benign pulmonary flow murmur

How well did you know this?

Not at all

Perfectly

An \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ murmur **will have normal intensity** and **normally split second heart sounds.** This pulmonary flow murmur may also be heard in the **presence of volume overload** from any cause such as chronic anemia, and following exercise. It may persist into adulthood.

adolescent with a benign pulmonary ejection

A pulmonary flow murmur accompanied by a fixed split second heart sound suggests right-heart volume load such as an\_\_\_\_\_\_\_\_\_\_

atrial septal defect.

The patient: Should have their shirt/s off, or wear an examination gown Females _____________ and older should wear a gown with the opening infront Should be calm and quiet.

9 yo and above

The stethoscope: It should be your own!!!! This part of the stet is useed fo**r high pitched ( primarily systolic)sounds and press firmly**

**diaphragm**

This is a part of the stet that is **low pitched ( primarily diastolic ) sounds**, and press lightly

BELL

Diapragm should be small enough to fit on the chest of the patient it should have a tubing which is ______________ and has a size of \_\_\_\_\_\_\_\_\_\_\_ It should have earpiecesthat are comfortable and snug

short ( 16- 18 inches)

Should be quiet ( patient, family, exam room, surrounding areas) * may briefly disconnect ventilator or occlude suction devices * **BRIEF bilateral occlusion** of infant nares **( warn the parents first**)) * should be well lit

environment

the order of CVS examination ins pedia is :

Inspection Palpation Auscultation \*\*\*\* Percussion is ommitted)

chest observation gives clues to cardiopulmonary diseases can be insensitive

INSPECTION

in the inspection, an asymmetry is an indicative of:

RVE

INSPECTION: Increased A-P chest diameter indicates \_\_\_\_\_\_\_\_\_\_\_\_

chronic air trapping/ hyperinflation

INSPECTION \_\_\_\_\_\_\_\_\_\_\_- can cause displacement of the heart

PECTUS EXCATUM Note : a Latin term meaning hollowed chest)[1] is the most common congenital deformity of the anterior wall of the chest, in which several ribs and the sternum grow abnormally. This produces a caved-in or sunken appearance of the chest.[2] It can either be present at birth or not develop until puberty. Pectus excavatum is sometimes referred to as cobbler's chest, sunken chest, the crevasse, or funnel chest. The hallmark of the condition is a **sunken appearance of the sternum**. The heart can be displaced and/or rotate**d.Mitral valve prolapse **may also be present. Base lung capacity is decreased

INPECTION: is a horizontal groove along the lower border of the thorax corresponding to the costal insertion of the diaphragm; It is usually caused by chronic asthma or obstructive respiratory disease. It may also appear in ricketsbecause the patients lack the mineralized calcium in their bones necessary to harden them; thus the diaphragm, which is always in tension, pulls the softened bone inward. During rickets it is due to the indentation of lower ribs at the point of attachment of diaphragm. It is named after Edwin Harrison

Harrison's groove, also known as Harrison's sulcus

Sometimes overlooked Use the most sensitive portion of the hand Lay the heel of **R hand at Left sternal border with fingertips pointing to left of the axilla**

PALPATION

Found the fingertips during palpation note interspace location, relatioo the midclavicular / anterior axillary line, amplitude

Apical impulse/ apex bear/ PMI

The strong impulse in apical impulse / apex bear/ PMI is due to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

increased CO or LVH

The Downward/ leftward displace in PMI is \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

LVH

This disease can shift PMI posterior ( making it difficult to palpate)

RVH

Palpation of loud murmur/ felling or rumbling

Thrills

Forceful, systolic thurst that moves the palpating hand up a little

Heave

A heave is an vindicative of

RVH

This is usually not performed for cardiac borders, but for lung fields

percussion

The bread and butter of the business

Where to listen in auscultaion? Mitral area tricusp and secondary aortic area aortic area pulmonary area

APEX/ 5 LICS ( mitral area) Left lower sternal border/ 4 LICS: **( tricuspid and secondary aortic area)** **upper Right sternal border/ 2RICS ( aortic area)** Upper left sternal border/ 2LICS: **pulmonary area**

lWhere else to listen?

Left and right infraclavivular areas Left anterior axillary line R and L axillae R and L interscapular areas of back ( for pulmonary / aortic collaterals)

AUSCULTATION: How to listen ?

Have a system, e.g. method of inching Listen systematically: s1, s2, systolic sounds, systolic murmurs, diastolic sounds , diastolic murmurs

(real) Normal heart sound

LUB DUP

Closing of the mitral and tricuspid valves

s1 is best heard at the \_\_\_\_\_\_\_\_\_\_\_\_

apex and LLSB

Tends to be more low- pitched and long as compared to S2

Occurs with high cfever, exercise, ardiac output such as thyrotoxicosis

LOUD S1

A soft S1 occurs with the following \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1. impaired myocardial contraction 2. CHF 3. mitral regurgitation 4. slowed venricular ejection rate 5. mitral insufficiency 6. increased chest wall thickness 7. pericardial effusion 8. hypothyroidism 9. cardiomyopathy 10. aortic insufficiency 11.

how to differential S1 from S2 ?

by palpating carotid pulse Note: S1 comes before and S2 comes after carotid upstroke

From closure vibrations of aortic and pulmonary valves often ignored, but it can tell much

S2 is divided into :

A2 and P2 Note: A2 : aortic P2 : pulmonary closure sounds Aortic closes before pulmonic

This is best heard at LMSB/ 2LICS Higher pitched than S1-- better heard with diaphragm

Normally split is due to different impedance of sytemic and pukmonary vascular beds audible splut with \> 20msec difference Split in 2/3 of NB by 16 hrs of age, 80 % by 48 hrs hard to discer in heart rates \> 100 bpm

S2 splitting ( normal)

Respiratory variation causes increase splitting on inspiration: decrease pulmonary vascular resistance , increase pulmonary blood flow When supine, slight splitting can occur in expiration when upright S2 usually become single with expiration

S2 splitting ( normal, cont)

Single S2 occurs with greater impedance to pukmonary fow,P2 closer to A2

single S2

Single and loud A2 :

TGA, extreme ToF Truncus arteriosus

Single and loud P2:

Pulmo HPN

Single and soft

ToP

Loud ( not single ) A2:

CoA or Ai

What are extra heart sounds?

1. S3 2. S4 3. Clicks 4. Friction rub

Usually physiologic in infants and children low pitched sound, occurs with rapid filling of ventricles in earlly diastole Due to sudden intrinsic limitation of longitudinal expansion of ventricular wall Makes Ken- tuck- y- thytm on auscultation

S3 + tachycardia

Gallop ( galloping horse)

best heard with patient supine or in left lateral decubitus increases by exercise, abdominal pressure or lifting legs

LV S3 is heard at \_\_\_\_\_\_\_\_\_\_\_ RV S3 is hear at \_\_\_\_\_\_\_\_\_\_\_\_

apex LLSB

Nearly always pathologic Can be normal in elderly or athletes low pitched sound in late diastole Due to poor compliance causing vibration in stiff ventricular myocardium as it fills **Makes " Ten-nes-see" rhythm** Better heard at the **apex or LLSB** in the **supine or left lateral decubitus position**

S4 gallop

S4 associiations are:

CHF HCM severe systemic HTN Pulmonary HTN myocarditis tricuspid atresis TAPVR CoA AS with severe LV disease Kawasaki;s disease

Usually pathologic Snappy, high pitched sound usually in early sytole Due to vibration in the artery distal to a stenotic valve

Click

Click can be associated with:

valvar aortic stenosis or pulmonary stenosis Truncus arteriosis Pulmonary atresia/ VSD Bicuspid aortic valve Mitral Valve prolaps Ebstein's anomaly

Creaking sound hear with pericardial imflammation changes with position, louder with inspiration caused by pericardial effusion, and can be heard in a limted area in the left left parasternal space

Friction rub

Sounds made by turbulsence in the heart of blood stream Described as **wooshing sound** ** can be benign ( Innocent, flow, functional) or pathologic** **murmur are the leading cause for referral for further evaluation** **Dont let murmurs distract youffrom the rest of the exam**

Murmur

When do murmurs occur?

They occur when blood makes a: * Forward flow through a constrict/ stenosed valve * ( i.e systole = pulmonic valve stenosis and Aortic valve stenosis. * Diastole = Tricuspid valve stenosis, Mitral valve stenosis. * backwarflow/ regurgitation through a prolapsing valve ( ie mitral valve prolapse, through which the blood flows from the left ventricular back into the left atrium * Backward flow of the blood through a septal defect * (ASD/ atrial septal defect = communication between the left and right ventricles; * VSD = communication between the left and right venricles * Flow of blood through " persistent" fetal structure * ( ie. Patent foramen ovale and patent ductus arteriosus

What is the first step in investigating a murmur

**Identify the normal heart sounds ( S1 and S2 )** **►** **analyze the murmur**

Grading of intensity or loudness

graded on a 6 point scale: grade 1: very FAINT grade 2: quiet but heard immediately grade 3: moderately loud grade 4: loud grade 5: heard with stethoscope partyly off the chest Grade 6: no stethosopce needed Note: THRILSS ARE ASSOCIATED WITH MURMURS of GRADES 4-6

Murmurs are longer than heart sounds HS can be distinguised by simultaneous palpation of the carotid arterial pulse systolic, diastolic, continuos

Timing

LOCATION Area: UPPER RIGHT STERNAL BORDER ( 2nd RICS)

aortic stenosis, venous hum

Upper left sternal border ( 2nd LICS)

Piulmonary stenosis Pulmonary flow murmurs Atrial septal defect PDA

Lower left sternal border ( 5th LICS)

Stiff's murmur ventricula septal defect tricuspid valve regurgitation hypertrophic cardiomyopathy subaortic stenosis

Apex ( 5th ICS LMCIS)

Mitral valve regurgiitation

RAdiation: To the neck? axilla? upper or lower sternal border back

General rule of thumb: is that the sound radiates in the direction of the blood flow

A murmur can radiate to different locationss from its origin, and this can be an important clue because it correlates with the direction of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

blood flow

Systolic ejection murmur ( AS vs MR vs VSD)

the murmur of aortic stenosis tends to radiate to the common carotid arteies, wheres mitral regurgitaion classically radiates to the left axiilla. A VSD does not radiate to those areas

Other characteristics: shape

crescendo decrescendo up-down plateau

other charac: ## Footnote pitch

high mild low

other charac of murmurs

quality blowing harsh rumbling musical

What are the variations in murmurs?

Variation with respiration ( R- sided murmurs change more tha n L- sided) Variation with position of patient variation with special maneuvers

Definition: contractio of ventricles

SYSTOLE

contraction of atrium / relaxzaiton of ventricles

diastole

the valvels are hard/ stiff such that they make a snapping sound when they are open.

stenosis Notes: this happens in pulmonary valve stenosisenosis a, mitral valve stenosis ic and aortic valve stenosis. Sometimes the valves become too "stenosed/ hardened" such that there may be a tendency for a forward flow to be interrupted. If such happens in aortic valve stenosis, there will be lack of oxygenized blood pumped into the systemic circulation, thus causing sudden fainting of an otherwise seemingly normal patient.

backward flow thorugh the blood

regurgitation

What are the types of murmurs ## Footnote

I. systolic * Ejection 1. innocent murmur 2. aortic stenosis 3. pulmonic stenosis 4. atrial septal defect * Holosystolic/ pansystolic 1. mitral regurgitation 2. mitral valve prolapse 3. tricuspid valve regurgitation 4. ventral septal defect II. ** diastolic** * A. Aortic regurgitaion * B. Mitral stenosis * C. pulmonic regurgitation III. Combined * A. PDA * B. Severe coarctation of the aorta

Begins **after the first heart sound**, increases in intensity immediately after, but wanes before it reaches the second heart sound

Systolic ejection murmur

1. Always systolic 2. Without evidence of any physiologic or antomic abnon and rmalities 3. grade 5/ 6 4. Varies considerably in position and level of activity 5. Does not radiate to the carotids nor axillae 6. Seen in up to 50 % of children, ussually 3-8 yrs old, then disappears by puberty 7. Low to medium pitched, best heard in 3rd- 4th ICS 8. Due to high cardiac output states and flow-related ( thyrotoxicosis, anemia, fever, exercise, pregnancy)

Systolic ejection murmur

What are the pathological systolic ejcetion murmur

B. Pathological 1. ASD 2. PS 3. AS

* Begins with 1st heart sound and continues through systole in a plateau like fashion beyond the 2nd heart sound * Terminates when the pressure in the left ventricle drops to the level of the left atrium during isovolimic relaxation * Little variation with respiration * flow from a high pressure chamber to a low- pressure chamber * May be absent in large lesions or in EISENMENGER SYNDROMES * seen in MR, TR, VSD

Holosystolic/ pansystolic Murmur

* Occurs in diastole beginning with the 2nd heart sound and ending just before the 1st heart sound * Low- pitched " **rumbling" -** mitral stenosis: occurs early in diastole and presystole; has an associated " opening snap" * high - pitched " regurgitaion" - aortic insufficiency

holosystolic / pandiastolic murmur

* Begins in systole ( or the 1st heart sound) , and extends through the 2nd ho part or all oear sound, into part or all of the diastole * PDA- from high pressure vessel ( aorta) to low- pressue vessel ( pulmonary artery

continuos murmur

What are the rechniques in enhancing auscultaion?

* inspiration- normally you should hear splitting of s2 with inspiration. P2 occurs later and moves farther away from A2 * Exhalation- can be used to evaluate right-sided heart murmurs. R-sided murmurs decrease with inhalation, while L-sided murmurs remain unchanged * Muller's maneuvers

this is a technique where in you ha patient pinch the nostrils shut with one hand and suck on a finger with the other ( creates prolonged negative intrathoracic pressure; shifts blood from systemic to pulmonary circulation

Muller's maneuver

standing to squatting- squattin increases stroke volume, and standing decreases it again * _________________ - as patient squats,this murmur should be decreased

Hypertrophic obstructive cardioyopathy

occasionally decreases in standing to squatting

mitral regurgitation

in squatting to standing this murmur increases

hypertrophic obstructive cardiomyopathy Note: mitral regurgitation ocassionally increases

mumur should decrease, as vLV increases and Lv enlarges

place blood pressure cuff on both arms and occlude blood flow for 20 secs Note: increases intensity : MR, VSD, other mumur unaffected

transient arterial occlusion

* Normal pulses; radial, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis * Rhtym abnormalities * Sinus arrrhytmia: pulse accelerates with inspiration * pulse deficit: with atrial affibrilation + tachycardia, the radial pulse is notconsecuiequal to the cardia apical pulse * Bigeminal pulse: 2 consecutive beats closely couples, with susbsequent pause after the next beat

Arterial pulse

Volume abnormalities: quick upstroke and full voliume ---\> seen in HPN and anxxiety

hyperkinetic pulse

Vvolime abnormalities: * a brisk pulse with large volume, collapsing pulse ( in aortic regurgitation)

Corrigans pulse

Volume abnormalities: This is a bifid oulse, 2 distinct impulses with each heartbeat, seen in aortic regurgitation, hypertrophic cardiomyopathy

pulse bisfiriens

volume abnormalities: This is a one pulse feels larger, the next one small = due to decreased cardiac contractility ( poor prognosis)

pulse alterans

Volume abnormalities: this is a weakening of pulse with inspiration more than normal (pericardial effusion, constrictive percarditis

pulse parodoxus

How is pulse being graded?

0= no pulse 3= normal pulse 4= bounding pulse

this is a temporary weakening of lower extremities due to arterial insuffficiency

intermittent claudication

atherosclerosis of abdomina aorta, reducing flow to lower exremities, leading to impotence

Leriche's syndrome

this is a pulseless disease -no pulse in arms due to progressiv obliterative arteritis

takayasus's arteritis

What vein is used in Cenral venous pressure

Right **internal jugular Vein is used**