Cardiac Short Case Flashcards
Right Thoracotomy scar cardiac ddx?
1) Pulmonary Artery banding
- to reduce pulmonary blood flow in lesions with left->right shunts or
- to “train” the left ventricle by increase after load (hypoplastic left heart) prior to definitive surgery
2) Shunt
Left thoracotomy scar cardiac ddx?
1) Coarctation of aorta repair
2) patent ductus ateriosis ligation
3) Shunt
4) Pulmonary artery banding
Median sternotomy scar?
All open heart corrections
Thoracotomy scar differentials?
1) Right sided lesions –> PA banding, closed valvotomies
2) Left sided lesions –> CoA, closed valvotomies
3) Connecting lesions –> PDA, shunt formation
4) TO fistula repair
5) Thoracic duct ligation
6) Valvular ring repair
Steps of Cardiac Exam?
1) Unwell or well
2) Breathless or not breathless
3) Cyanotic or not
4) Growth parameters
5) Vitals: BP (ask for 4 limb), Temp, RR, Urinalysis (ask for at end)
6) Iatrogenic: IVs, O2
7) Dysmorphology (Downs, Turners, Noonans etc)
8) Skin –> scars
9) Periphery:
- Hands/Arms: clubbed (look at feet too), SBE (splinter, Osler, Janeway), BP, antecubetal fossa scars
- Pulse (do upper and lower limb) - rate, rhythm, volume, form (lift up to detect hyperdynamic pulsation = aortic incompetence), radio-radial/radio/femoral delay, absent or decreased L) radial pulse (post coarct, post BT shunt)
10) Head:
- JVP (in older child, look at 45degrees, inc w RVF)
- Eyes: Pale conjunctiva, icterus, roth spots
- Mouth: central cyanosis
- Oral dentition state
- Carotids –> volume + form
11) Precordium
- Inspect: symmetry –> L chest prominence = chronic RVH, R chest prominence = dextrocardia with chronic ventricular hypertrophy. Apical pulsation
- Palpate: Apex, LLSE, LUSE, RUSE, supraclavicular. Heaves/thrills (inc suprasternal notch), palpable P2 (closure of pulmonary valve)
- Auscultate: Areas, HS, added sounds, Murmurs + radiation
12) Lungs:
- Feel deep in axilla for collaterals in CoA if suspected
- Auscultate at bases
- Sacral oedema
- Cough (PCD)
13) Abdomen: Hepatomegaly (pulsatile = TRR, Enlarged = RVF), Splenomegaly (SBE)
14) Legs: Pitting oedema
Normal hands w clubbed feet differential?
Eisenmengers w PDA
Hyperdynamic pulsation differential?
Aortic incompetence
Absent L) brachial pulse differential?
1) post CoA repair
2) Post Blalock-Taussig shunt repair (will also have L) thoracotomy scar)
JVP increased with what?
RVF
Supraclavicular murmur radiation?
L) = PDA
R) = Aortic stenosis
Carotid murmur radiation?
Aortic lesions
Axilla murmur radiation?
Mitral valve (roll them away from you)
Radiation of murmur to back?
1) Peripheral pulmonary stenosis
2) CoA
Murmur increased with Valsava with which lesions?
1) HOCM
2) Mitral valve prolapse (increased intensity and earlier click)
Murmur decreased with valsalva in which lesions?
Innocent murmurs
Murmur increased when sitting forward with which lesions?
Aortic regurgitation
What is an anacrotic carotid pulse and which lesions is it felt in?
1) Slow rising pulse/slow upstroke
2) Seen in severe aortic stenosis (small volume + slow upstroke)
AKA Plateau pulse
What is an BISFERIENS carotid pulse and which lesions is it felt in?
1) A double pulse is felt due to the backflow of blood in early diastole. The first carotid pulse felt is normal systole, while the second is actually early diastolic due to the regurgitating blood.
2) Seen in Aortic regurgitation (with or without aortic stenosis) + severe HOCM
- Small volume, slow upstroke, collapsing
What is a collapsing carotid pulse and which lesions is it felt in?
1) a pulse that is bounding and forceful, rapidly increasing and subsequently collapsing, as if it were the sound of a water hammer that was causing the pulse.
2) Seen in Aortic Regurgitation, PDA, Peripheral arteriovenous aneurysm
What is an Alterans pulse and which lesions is it felt in?
1) beat-to-beat variation in the amplitude of the pressure pulse —> alternating weak and strong beats best appreciated at peripheral pulses
2) Loud in: Mitral stenosis, tricuspid stenosis, hyperdynamic circulation
3) Soft in Mitral regurgitation, mitral valve calcification
A loud S1 signifies which issues?
1) Tricuspid stenosis
2) Mitral stenosis
3) Hyperdynamic circulation
A loud A2 signifies which issues?
1) HTN
2) Aortic stenosis
A loud P2 signifies which lesion?
1) Pulm HTN (may also have mid-diastolic murmur)
An increased split in S2 indicates which pathology?
1) RBBB
2) Pulmonary stenosis
3) VSD
4) Mitral regurgitation (earlier A2)
A fixed split S2 indicates which pathology?
ASD
What does an S3 indicate?
1) Can be normal in children
2) Volume overload in L or R heart e.g. PDA, VSD, LVF, RVF
What does S4 indicate?
Left or right ventricular hypertrophy
- L) = Aortic stenosis, systemic hypertension, HOCM
- R) = Pulmonary stenosis, pulm HTN
A soft A2 signifies which pathology?
1) Calcified aortic valve
2) Aortic regurgitation
A soft P2 indicates which pathology?
Pulmonary stenosis (soft A2 with loud P2 = PS with PHTN)
What is a reversed split and which lesions is it seen in?
P2 is before A2 (how am I supposed to hear this, honestly)
1) LBBB
2) Aortic stenosis
3) CoA
4) PDA