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PNP: Physical Assessment - BK > Cardio > Flashcards

Cardio Flashcards

1
Q

Cardiac History

A

Exercise tolerance, chest pain, syncope, family hx

Feeding difficulty

Hx of dizziness and syncope

Diaphoresis, congested cough, tachypnea

Perinatal hx

Maternal hx

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2
Q

Maternal use of NSAID and ASA

A

Increased risk of pulmonary hypertension of the newborn

Increased risk of premature closure of ductus

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3
Q

Maternal use of Lithium

A

Increased risk of Ebstein’s anomaly of the tricuspid valve

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4
Q

SLE

A

neonatal heart block

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5
Q

Diabetes

A

Cardiomyopathy

Transposition of the great arteries

Ventricular septal defect

PDA

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6
Q

Age Appropriate Hx

Infant

A

Growth

Check feeding

Color

Congested cough

Rapid deep breathing with SOB in a colicky baby suggests heart failure

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7
Q

School Aged Hx

A

Growth pattern

Chest deformity

Activity level

Difficulty in keeping up with activity

Hx of dizziness or syncope

Tires after activity

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8
Q

Family Hx

Maternal diabetes

Medications

Prenatal infection

A

Maternal diabetes: ASD, coarctation, cardiomyopathy

Prenatal Hx of medication use: Dilantin, coumadin, psychotherapeutics, antiepileptics

Prenatal infection: CMV, Coxsackie, Herpes

Family Hx

Prenatal Substance abuse

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9
Q

Physical Assessment Order

A

Inspection

Palpation

Auscultation

Percussion

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10
Q

General Physical Assessment

A
  • Vital Signs
    • Temperature
    • HR (sinus arrythmia)
    • RR (look for retractions, grunting, and nasal flaring)
    • BP
      • Pressure differential b/w right arm and lower leg
      • BP is HIGHER in leg
  • Activity level
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11
Q

Oxygen Saturation

A

75-85 is normal for children with right to left shunt

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12
Q

Faces

A

Central Cyanosis

Peripheral cyanosis

Acrocyanosis

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13
Q

Cardiac Evaluation Continued

A

Overall growth and appearance

Lungs – clear wheezing, grunting and rales

Peripheral perfusion/abdominal pain

Hepatosplenomegaly (1-2cm soft liver edge is normal, evaluate for position and size, critical indicator of cardiac output)

Extracardial anomalies

SACRAL EDEMA*****

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14
Q

Inspection (7)

A

Close observation of growth and development

Cyanosis

Look for precordial bulging, sign of right sided enlargement

Clubbing

VS

Jugular venous pulsation

Pallor, cyanosis, peripheral lymphedema

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15
Q

Pulse rate is increased by ______ for each centigrade of fever

A

10-15 bpm

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16
Q

Waterhammer or Corrigan’s pulse

A

pulse that is bounding and forceful, rapidly increasing and subsequently collapsing, as if it were the sound of a waterhammer that was causing the pulse.

PDA

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17
Q

Quincke Pulse

A

With a light held on the pad of the finger, gentle pressure is applied to the distal nail, if the pulse pressure (PP) is wide, alternating filling and blanching of the capillary bed can be seen

Aortic insufficiency

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18
Q

Premature Pulses

A

may have bounding pulses due to lack of subcutaneous fat and higher incidence of PDA

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19
Q

Assessment of pulses

A
  • Assessment of femoral and radial pulse
  • Palpate for thrill
    • Turn child to the left and feel the apex
    • Basal thrills are felt with child sitting up
    • Look for thrills at PMI and suprasternal notch
  • Pericardial friction rubs can be palpated
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20
Q

High frequency thrills along the LBD

A

Ventricular septal defect

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21
Q

Low frequency thrill in 2nd ICS suggests

A

Aortic stenosis

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22
Q

Diastolic thrill at the apex

A

mitral stenosis

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23
Q

Point of Max Impulse

A
  • Normal position of apex beat
  • 5th ICS space MCL after 7
  • Before this age, the apex best is in the 4th ICS to the left of the MCL
  • Determine ventricular overload
  • Cardiomegaly
  • Presence or absence of thrill
    • Turbulent blood flow
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24
Q

AUSCULTATE

A

Aortic

Mitral

Erb’s point

Tricuspid

Pulmonic

Infraclavicular – carotid and axillary

Posterior aspect under scapula

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25
Q

Listen for low pitched sounds of the diastolic murmur by listening for

A

the absence of silence during diastole

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26
Q

Age specific hits

Infants

A

Listen during feeding

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27
Q

Age specific hints

4months to 1 year

A

Listen while baby is being brough to sitting: Strain to sit up

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28
Q

Age specifc

TODDLER

A

Play with them once they have confidence in you

Give them time to warm up

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29
Q

7 S’s of innocent murmurs

A

Systolic

Short duration (not holosystolic)

Single (no clicks or gallops)

Small (do not radiate)

Sensitive (tend to change with position or respiratory effort – louder supine)

Soft

Sweet (no harsh sounds)

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30
Q

S1

Split S1

A
  • Due to closure of the tricuspid and mitral valve
  • Best heard at the left lower sternal border or at the apex
  • Split s1 can be normal in children but if wide can be right bundle branch block or Ebstein anomaly
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31
Q

S2

A

Due to closure of pulmonic and aortic valve

Aortic valve closes first

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32
Q

Distinguishing between Splitting and S3

A

Intensity

Quality

  • Split s2 of equal intensity and quality
  • Hear at base
  • Occur with very interval between sounds
  • Splitting at base is absence in pulmonic stenosis, tetralogy of fallot, pulmonic atresia or truncus

Position Heard

Distance between sound

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33
Q

Murmurs

A

Murmurs are produced when the blood velocity becomes critically high in the presence of an irregularity or narrowing of the surface over which the blood flows.

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34
Q

The loss of laminarity

A

Results in turbulence which in turn produces a sound.

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35
Q

Etiology of Murmurs

A
  • The frequency of the sound from the turbulence varies directly with velocity of the blood flow.
  • High sound frequencies are associated with high velocity jets as in mitral regurgitation with the flow from the high pressure left ventricle to the low pressure left atrium
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36
Q

Aids to Auscultation

A

Quiet patient

Quiet room

No distractions

Good Stethoscope

Good hearing

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37
Q

Types of murmurs

A

Systolic – ejection, holosystolic or regurgitant

Diastolic – early decrescendo, mid-diastolic

Continuous = PDA

38
Q

Characteristics of Murmurs

A

Timing – systolic, diastolic, continuous

Intensity – standard scale

Quality – frequency and pitch

39
Q

Intensity of the murmur

A

The velocity of the blood

The volume of blood causing the murmur

The distance from the site of the origin of the murmur to the stethoscope

40
Q

Grading of the murmur

A
  • 1/6 Faint, not easily heard
  • 2/6 Faint but heard immediately
  • 3/6 Loud but no thrill
  • 4/6 Loud with a thrill
  • 5/6 Loud with a thrill and heard with the edge of the stethoscope on the chest
  • 6/6 Heard with the stethoscope 1 cm. off of the chest wall
41
Q

Third Heart Sound

A
  • Associated with ventricular filling
  • Louder in the non-compliant left ventricle
  • Louder with increased blood flow/cardiac output
  • Intermittent S3 may be a normal variant
42
Q

Extra Cardiac Sounds

A

Friction rubs

Bronchial sounds

Rales

Pleural rubs

Wheezes

43
Q

Radiation of the murmur

A

Direction of blood flow

Site of Origin

Intensity of murmur

44
Q

Chest X-ray and Cardiac Anomalies

Tetralogy of Fallot

A

Boot sign

45
Q

Chest X-ray and Cardiac Anomalies

Transposition of great arteries

A

Egg on a string sign

46
Q

Chest X-ray and Cardiac Anomalies

Total Anomalous Pulmonary Venous Connection

A

Snowman sign

47
Q

Chest X-ray and Cardiac Anomalies

Partial anomalous pulmonary venous return

A

Scimitar sign

48
Q

Innocent murmur

A

Systolic

Less than 4/6 (no thrill)

Generally increased with fever, anemia, anxiety, excitement

Sitting or standing decreases murmur due to venous pooling

Several specific types

49
Q

5 innocent murmurs of childhood

A

Still’s murmur

Pulmonary flow murmur

Peripheral pulmonic stenosis murmur

Supraclavicular bruit

Venous hum

50
Q

Still’s murmur

A

Caused by uniform periodic vibration of the left heart structure

First heard during sick visit in preschooler and usually disappears in puberty

Most common innocent murmur

51
Q

Still’s murmur characteristics

A

Short, systolic

Vibratory, buzzing hocking

Lower left sternal border

Most common 3-7 years

Louder supine

Decreases significantly or disappears with Valsalva

52
Q

Pulmonary ejection murmur

A
  • Probably from mildly turbulent flow in right side of heart
  • Short, systolic ejection
  • Upper left sternal
  • All ages (rare in infants) Much more common in late childhood and early adolescents
  • Louder with expiration
  • Normal S2 split
53
Q

Pulmonic ejection murmur characteristics

A
  • Thin body habitus
  • Straight back syndrome
  • Increase cardiac output
  • Increases with supine position
  • Increased with fever, anemia
  • Varies from I-III/VI
  • Left and right sternal border, transmit to back
  • Best heard in supine position with exhalation
  • Intensifies with exercise
54
Q

Peripheral pulmonic branch stenosis

A
  • Turbulence arising the acute angle at which the relatively small branch pulmonary arteries take off from the main pulmonary artery
  • Systolic, ejection which disappears by six months
  • If it does not disappear by six month, severe branch pulmonary artery stenosis is associated with Williams syndrome and congenital rubella
  • Chest and axillae (often loudest in axillary
  • New born infants and early well child check
55
Q

Supraclavicular carotid bruit Cause

A

Caused by turbulence at the take off area of the brachiocephalic and carotid arteries from the aortic arch

56
Q

Supraclavicular Carotid Bruit Characteristics

A
  • Systolic and ejection, high pitched, harsh
  • Best heard in supraclavicular fossa on the right more than left
  • Does not radiate far
  • Supraclavicular region and neck
    • Not heard below clavicle
    • Not affected by sitting or lying
    • Decreased by hyperextension of shoulder
57
Q

Venous Hum

A
  • Continuous (lounder in diastole)
  • Supraclavicular
  • Right more common than left
  • Disappears with change in head position, digital pressure, lying spine
  • Loudest when sitting or standing
58
Q

When to refer: Neonate

A
  • Murmurs are common in neonates
  • Absence of murmur does not mean no heart disease
    • Loud or long murmur
    • Murmurs radiating to back
    • Appears ill
    • Any diastolic murmur
    • Abnormal CXR or EKG
    • Dysmorphic features
    • Abnormal cardiac sounds
      • Clicks, rubs, abnormally split S2 or single S2
59
Q

Clues to Cardiac Disease in Neonates

A

Cyanosis

Tachypnea

Tachycardia

Diaphoresis

Gallop

Abnormal splitting of S2

Abnormal precordial activity

Hepatomegaly

Abnormal pulses

BP lower in lower extremities

Mottled extremities

60
Q

Significant Hx

A
  • Tachypnea
  • Feeding intolerance
  • Poor weight gain
  • Exercise intolerance
  • Excessive fatigue
  • Frequent respiratory infections
  • Syncope
  • Persistent cough, wheezing (not associated with asthma
  • Chest pain with exertion
  • Cyanosis
  • Palpitations
61
Q

When to refer over 6 weeks

A

Abnormal pulse or BP

Abnormal S1 or S2

Displaced apical impulse

Click, gallop, rumble

Murmur – diastolic, continuous (if not venous hum), loud

62
Q

Murmurs needing Eval

A

Murmurs in symptomatic kids

Loud murmur

Diastolic murmurs

Murmurs that don’t fit into categories of innocent murmur

63
Q

Congenital heart disease

A

Presenting as an asymptomatic murmur

64
Q

Septal

A

ASD, VSD

65
Q

Obstruction to ventricular outflow

A

Valvar, subvalvular or supravalvar aortic or pulmonic stenosis

Coarctation of aorta

PDA

66
Q

What causes systolic murmur

A
  • Turbulence in ventricular outflow
    • Narrowing of aortic or pulmonary valve, aorta or pulmonary artery
    • Increased flow
  • AV valve regurgitation
  • Abnormal ventricular or arterial communications
    • VSD or PDA
67
Q

Aortic Valve Stenosis

Intro

A

Occurs in 5% of children with CHD

May have associated defect such as coarct, VSD or PDA

Non obstructive isolated bicuspid aortic valve is most common congenital defect which occurs in 1% of the population

68
Q

Presentation of Aortic Stenosis

A

Most common is just a murmur

If very narrow valvular opening, needs the right to left shunting available through the PDA and may present acutely with shock or CHF if ductus closes

Can progress over months

69
Q

Aortic Stenosis Presentation cont. (4)

A
  • May be valvar, subvalvar or supravalvar
  • Systolic ejection murmur begins early in systole after the click
    • Medium to high pitched
    • Upper right sternal border to apex
    • Radiation to neck
    • Click helps distinguish it from pulmonary flow murmur
  • May have a thrill in suprasternal notch or in carotid arteries area
  • Valvar AS usually cases a systolic ejection click at the apex
  • Click is not present in the most severe cases
70
Q

Pulmonic Stenosis

A
  • Systolic ejection murmur
  • Upper left sternal border
  • Radiation to back
  • Systolic ejection click at lower left sternal border which varies with respiration
  • May have thrill in suprasternal notch
  • Harsh loud murmur
71
Q

Patient Ductus Arteriosus

A
  • Blood from right ventricle into descending aorta, bypasses the lungs
  • PDA normally closes by 48 hours after birth
  • Direction of shunt depends upon the differential resistance between the aorta and pulmonary artery
  • Right to left ductal shunting occurs with severe left heart obstructive lesions
    • Severe coarctation
    • Hypoplastic left heart
    • Normally left to right shunting
72
Q

Patent ductus arteriosus

Presentation

A
  • Prematurity
    • May have pulmonary overcirculation and will present early
  • Infants and children tend be completely asymptomatic
    • If infant is going to present with pulmonary overcirculation, does so when the pulmonary resistance falls at 4 to 6 weeks.
    • Single S2 = pulmonary hypertension
73
Q

Patent ductus arteriosus

2

A

Wide pulse pressure

Bounding pulses – waterhammer pulse

Quincke pulse on finger tips

74
Q

Coarctation of Aorta

A
  • Narrowing of aortic arch adjacent to the site of ductus
  • Systolic ejection murmur below left scapula
  • Decreases pulse and BP in lower extremities
  • If severe, causes shock
  • Often associated with bicuspid aortic valve
75
Q

Ventricular Septal Defect

A
  • Holosystolic murmur
    • Harsh, high pitched if VSD is small
  • Diastolic rumble at Apex
  • CHF is VSD is large
    • Increased LA pressure
    • Pulmonary edema
    • Increased work of breathing
    • Poor growth
  • Can lead to pulmonary hypertension if not found
76
Q

Ventricular Septal Defect (2)

A
  • At birth PVR is greater than SVR and shunt is right to left or bidirectional
  • As PVR falls, then left to right shunt and murmur appears
  • Pitch depends on whether right to left or left to right
  • Diastolic rumble
  • Caused by vibration of the mitral valve as the large volume of flow from the lungs goes into the left ventricle
  • Much more likely to be moderate in intensity
77
Q

VSD (3)

A

Can have a normal to wide split S2 which will vary with respirations

Increase volume traversing the pulmonary valve causes it to close later

Loudness of murmur does not correlate with size of the defect

Plateau shaped murmur with the same intensity throughout.

78
Q

Atrial Septal Defect

A
  • Systolic ejection murmur
  • Upper left sternal border
  • Wide fixed split S2
  • Right ventricular impulse
  • Diastolic rumble at lower left sternal border
  • CHF not seen
  • Subtle exercise intolerance
79
Q

What causes diastolic murmurs?

A
  • Turbulence in ventricular inflow
    • Narrowing
    • Increased flow
  • Semilunar valve regurgitation
80
Q

What causes continuous murmurs

A
  • Abnormal systemic to pulmonary artery communications
    • PDA
  • Abnormal arteriovenous communications
    • AV fistula
    • Coronary artery fistula
81
Q

Common murmurs in first days of life

NORMAL

A
  • PPS
  • Pulmonary flow murmur
  • Transitional murmurs
    • Closing PDA
    • Transient tricuspid regurgitation
82
Q

Common murmurs in first days of life

ABNORMAL

A
  • Outflow obstruction
    • AS
    • PS
    • Coarctation
  • Abnormal communications
    • VSD
    • PDA
83
Q

Transitional murmurs

A

ULSB or left infraclavicular area

Systolic or continuous

Often louder as PDA gets smaller

Occasional vibratory

Typically 12 to 48 hours of age

84
Q

Transient Tricuspid Regurgitation

A
  • LLSB
  • Regurgitant, systolic
  • Often seen with asphyxiated infants or infants with pulmonary hypertension
  • Takes several days to resolve
85
Q

Complex Congenital Heart disease

A
  • Ebstein anomaly
  • Common AV canal (truncus)
  • Tetralogy of Fallot
  • Hypoplastic left heart
  • Transposition of the great vessels
86
Q

CHF History Child

A

Decreased exercise capacity

Fatigability

SOB

Weight gain or loss

87
Q

CHF History – infant

A

Poor weight gain

Cachexia

Malnutrition

Sweating when feeding

88
Q

CHF Hx

Adolescent

A

Fatigue

Cold intolerance

Exercise intolerance

Syncope

Dizziness

89
Q

CHF physical Exam

First sign = TACHYCARDIA

A
  • Infant heart is stiffer and less distensbile so they increase rate as they cannot increase stroke volume
  • Tachypnea
  • Hepatomegaly
  • Edema
  • Ascites
  • Diminish perfusion
  • Pedal edma and neck veing distention are rare
  • Listen for gallop
90
Q

Hypertrophic Cardiomyopathy

A
  • May have biventricular outflow tract obstruction in infancy
  • Older children asymptomatic
  • May have murmur
  • Pulse may be diminished as ventricular ejection is impeded
  • Listen to murmur squatting and then have the patient stand.
  • MURMUR WILL greatly INCREASE IN INTENSITY as child stands
91
Q

Hypertrophic cardiomyopathy

POSITIONS

A
  • Maneuvers that increase the intensity and duration of the murmur
    • Decrease preload
      • Strain of Valsalva
    • Increase contractility
      • Exercise
    • Decrease afterload
      • Stand suddenly
  • Maneuvers that will decrease the intensity and duration of the murmur (this is the opposite of what you would expect)
    • Increase afterload
      • Squat or hand grasp
    • Increase preload
      • Raise legs
92
Q
A

PNP: Physical Assessment - BK (13 decks)

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