Cardiology Flashcards
What is cardio core exam?
1) IC HIUG DEPV
· Iatrogenic - O2, IV, NGT
· Growth
· Dysmorphism - syndromes
· Vitals - Cyanotic/acyanotic
2) Nails and Hands * Perfusion, peripheral cyanosis, clubbing * Pallor palmar creases 3) Pulse + RR - count out, rate, rhythm, volume - Radio-radial delay - Radio-femoral delay - Brachial pulses if younger 4) Arm - Scars, - Muscle bulk - BP 5) Neck - JVP (older child) - Carotid pulse (older) 6) Face - dysmorphic features 7) Eyes - Conjunctival pallor - Scleral icterus - Nerve palsy - post op 8) Mouth - Central cyanosis - Dentition 9) Chest Inspect - Scars - sit up, lift arms - Chest shape - Resp distress Feel - Apex beat - Heaves, thrills in all areas Auscultate - Apex, LLSE, LUSE, RUSE, supraclavicular - Heart sounds - Murmurs - Additional sounds - Radiation - axilla, carotids, back - Manoeuvres if appropriate - Valsalva - increase murmur HOCM, decrease murmur with Valsalva- innocent, sitting upright/forward - increase AR 10) Respiratory - Listen at back - Sacral edema - Cough 11) Abdomen - Hepatomegaly - Splenomegaly 12) Legs - Groin - catheter - Peripheral edema - Muscle bulk - Pulses
Ask for
- ECG
- CXR
- Chromosomal testing
Complications of Congenital heart disease to examine?
· Growth - poor growth
· Anaemia - pale conjunctiva, palmar crease pallor
· Puberty
· Stroke - hemiplegia
Development
Summary - cardiac short?
Summary - Cardiac
- Asked to perform cardiovascular exam
- John in a 4 y.o M
- Salient examination findings:
· Cyanotic/acyanotic
· Well grown/poor growth, appear developmentally appropriate
· Evidence/no evidence of heart failure, pulmonary hypertension
· Syndrome/non syndromic
· Evidence/no evidence previous cardiac surgery, XX scars
Murmur:
· Systolic - pan, ejection
· Loudest in X
· Radiation to X
· Previous surgery - cardiac murmur consistent residual lesion
· Cyanotic - complex cardiac lesion
· Acyanotic - congenital heart lesion with partial correction
· Murmur is most consistent with x · My differentials are X To narrow down differentials I would like to see ECG and CXR
Reporting ECG
· 12 lead ECG of John taken X
· Normal calibration
· Rate is X bpm appropriate for age
· Rhythm regular, P wave before each QRS, PR interval constant, P wave axis constant. Sinus rhythm/arrythmia
· Axis is X
· P waves - normal morphology - peaked (RAE), bifid (LAE)
· PR interval normal
· QRS complexes normal duration, progression across precordium
- With/without evidence of BBB
- With/without evidence of pre-excitation
- With/without evidence of RVH or LVH
- RVH: right axis, upright T wave V1, tall R wave V1 (4 large squares), deep S wave V6 (1 large square), ST segment changes strain
- LVH: left axis, deep S wave V1, tall R wave V6, T wave inversion lateral leads, Q waves
· T wave inverted/upright in V1 normal for age
· QT interval grossly normal calculate Bazett’s
Summary - normal SR, axis X, normal P, criteria for X
Reporting CXR structure?
· Check right is viewing on our left side
· This is AP/PA CXR of John taken X
· Well centred, good penetration (rotated film)
· Anything extra - sternal wires, NGT, pacing wires
· Heart size/shape
- Should be <50% on PA, < 60% on AP
- Shape
- Arch
· Lung fields
- Oligemic, plethoric
- Pleural effusion
- Pneumothorax
· Thymic shadow
· Gastric bubble
Spina/rib/bone abnormalities
Voltage criteria for RVH and LVH?
3 - > 3 squares R V1 - RVH
1 - > 1 square S V6 - RVH
3 - > 3 square S V1 - LVH
5 - > 5 squares R V6 - LVH
RVH criteria?
- Upright T wave V1
- RAD
Voltage criteria - 3 - > 3 squares R V1 - RVH, 1 - > 1 square S V6 - RVH
LVH?
- LAD
- Voltage criteria - 3 - > 3 square S V1 - LVH, 5 - > 5 squares R V6 - LVH
T wave inversion in V5/V6
DDx for systolic murmur RUSE?
LVOTO (Ejection systolic, radiates to carotids)
* Valvular - aortic stenosis (click, suprasternal notch thrill)
* Supravalvular: William’s
* Subvalvular: HOCM (louder with Valsalva)
Increased flow:
* Anaemia, fever
RVOTO (ejection systolic, expect louder at LUSE, radiates to back)
DDx for systolic murmur at LUSE?
LUSE
Ejection systolic
RVOTO (ejection systolic, radiates to back)
* Valvular: pulmonary stenosis (click) - wide split S2
* Subvalvular: HOCM (rare)
* Supravalvular, branch
* TOF or post TOF repair - long harsh systolic murmur, cyanosis
Increased flow
* Anaemia, fever, shunt
Manoeuvre - pulmonary -sit upright, inhale
LVOTO (louder at RUSE)
Pansystolic
ASD
Fixed S2
DDx for systolic murmur LLSE?
Pansystolic
VSD (+ AVSD)
* Pan systolic
* Diastolic rumble at apex
* Blood moves across during systole
* Pansystolic, loudest at LLSE, harsh
* If high PBF - apical mid diastolic murmur (more blood flow across mitral valve)
Tricuspid regurgitation
* Blowing, holo-systolic at LLSE
* During systole, blood moves back over tricuspid valve
* Increasing with inspiration and reducing with Valsalva
* Neck vein distension
* Pulsatile liver
Innocent/Still’s murmur
DDx for systolic murmur apex?
Apex/Mitral Area
Systolic
Mitral regurgitation (pansystolic)
* Leaky mitral valve, leaks blood back during systole
* Holosystolic murmur best heard mitral area/apex
* Radiates to axilla
* Radiates to back or clavicular area (with systolic click in MVP)
* *Rheumatic heart - most common
Manouvre mitral: left lateral, exhale
Mitral valve prolapse (mid systolic click)
* Systolic click
Systolic murmur
DDx - diastolic murmur?
RUSE
Aortic regurgitation
LUSE
Pulmonary regurgitation
* Blood flows back across pulmonary valve during diastole
* Manouvre - increases on inspiration
Mid-diastolic
LLSE
Aortic regurg
Tricuspid stenosis
* Hard to get blood through tricuspid valve during diastole
* Tricuspid area
Apex
Mitral stenosis
* Hard to get blood through mitral valve during diastole - diastolic
* Mitral area
* Opening mitral snap - early diastolic filling
DDx continuous murmur?
PDA (loudest LUSE)
* Blood flows either from pul artery into aorta or aorta in pul artery - continuous, machinery like
* LUSE (pulmonary )left infra-clavicular, with bounding pulses
BT shunt (central scar)
Venous Hum
* Age 3-6, no other issues
AV malformation
Collateral vessels (eg. PA + VSD + MAPCAs)
Aneurysm
Dynamic Manouvres?
- Aortic - sit forward, exhale
- Pulmonary - sit upright, inhale
- Mitral - left lateral decubitus, exhale
- Tricuspid - 45 degree (bed) inhale
Valsalva - louder (HOCM), softer (LVOTO)
