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2H. Physical Diagnosis > CVS- PED > Flashcards

CVS- PED Flashcards

1
Q

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

A

True

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2
Q

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

A
  • the fear/s of their patient
  • their inability to cooperate
  • (in many instances), their desire to play
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3
Q

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

A

2 yr old

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4
Q

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

A

something t-o hold in each handà

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5
Q

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

A

Endless chatter

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6
Q

USE YOUR KNOWLEDGE OF THE DEVELOPMENTAL STAGE OF EACH CHILD

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

A

True

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7
Q

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

A

** increased likelihood of congenital cardiac disease**

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8
Q

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.

A

3 to 4

*coarctation of the aorta

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9
Q

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

A

coarctation of the aorta

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10
Q

_____________children often have benign murmurs.

A

Preschool and school-­‐aged

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11
Q

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

A

Still’s murmur

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12
Q

__________- à disappearance of the precordial murmur

A

Carotid artery compression

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13
Q

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

A

fever or exercise.

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14
Q

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)

A

Venous hum

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15
Q

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.

A

Carotid bruit

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16
Q

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

A

signify underlying heart disease

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17
Q

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

A

after infancy and during childhood.

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18
Q

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.

A

carotid
bruit.

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19
Q

Location and Characteristics of Benign Heart Murmurs in Children*

A
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20
Q

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

A

Still’s murmur

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21
Q

Preschool or early
school age

Venous hum

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

A

Venous hum

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22
Q

Preschool and later

Early and midsystolic
Usually louder on left
Eliminated by carotid compression

A

Carotid bruit

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23
Q

Older child, adolescence and later

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

A

Pulmonary flow murmur

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24
Q

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.

A

benign pulmonary flow murmur

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25
Q

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.

A

adolescent with a benign pulmonary ejection

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26
Q

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

A

atrial septal defect.

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27
Q

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.

A

9 yo and above

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28
Q

The stethoscope:

It should be your own!!!!

This part of the stet is useed for high pitched ( primarily systolic)sounds and press firmly

A

diaphragm

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29
Q

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

A

BELL

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30
Q

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

A

short ( 16- 18 inches)

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31
Q
A
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32
Q

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
A

environment

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33
Q

the order of CVS examination ins pedia is :

A

Inspection

Palpation

Auscultation

**** Percussion is ommitted)

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34
Q

chest observation gives clues to cardiopulmonary diseases

can be insensitive

A

INSPECTION

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35
Q

in the inspection, an asymmetry is an indicative of:

A

RVE

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36
Q

INSPECTION:

Increased A-P chest diameter indicates ____________

A

chronic air trapping/ hyperinflation

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37
Q

INSPECTION

___________- can cause displacement of the heart

A

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

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38
Q

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

A

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

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39
Q

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

A

PALPATION

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40
Q

Found the fingertips during palpation

note interspace location, relatioo the midclavicular / anterior axillary line, amplitude

A

Apical impulse/ apex bear/ PMI

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41
Q

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

A

increased CO or LVH

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42
Q

The Downward/ leftward displace in PMI is ____________________________

A

LVH

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43
Q

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

A

RVH

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44
Q

Palpation of loud murmur/ felling or rumbling

A

Thrills

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45
Q

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

A

Heave

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46
Q

A heave is an vindicative of

A

RVH

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47
Q
A
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48
Q

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

A

percussion

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49
Q

The bread and butter of the business

A
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50
Q

Where to listen in auscultaion?

Mitral area

tricusp and secondary aortic area

aortic area

pulmonary area

A

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

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51
Q

lWhere else to listen?

A

Left and right infraclavivular areas

Left anterior axillary line

R and L axillae

R and L interscapular areas of back ( for pulmonary / aortic collaterals)

52
Q

AUSCULTATION:

How to listen ?

A

Have a system, e.g. method of inching

Listen systematically: s1, s2, systolic sounds, systolic murmurs, diastolic sounds , diastolic murmurs

53
Q

(real) Normal heart sound

A

LUB DUP

54
Q

Closing of the mitral and tricuspid valves

A

S1

55
Q

s1 is best heard at the ____________

A

apex and LLSB

56
Q

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

A

S1

57
Q

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

A

LOUD S1

58
Q

A soft S1 occurs with the following __________________

A
  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.
59
Q

how to differential S1 from S2 ?

A

by palpating carotid pulse

Note: S1 comes before and S2 comes after carotid upstroke

60
Q

From closure vibrations of aortic and pulmonary valves

often ignored, but it can tell much

A

S2

61
Q

S2 is divided into :

A

A2 and P2

Note: A2 : aortic

P2 : pulmonary closure sounds

Aortic closes before pulmonic

62
Q

This is best heard at LMSB/ 2LICS

Higher pitched than S1– better heard with diaphragm

A

S2

63
Q

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

A

S2 splitting ( normal)

64
Q

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

A

S2 splitting ( normal, cont)

65
Q

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

A

single S2

66
Q

Single and loud A2 :

A

TGA,

extreme ToF

Truncus arteriosus

67
Q

Single and loud P2:

A

Pulmo HPN

68
Q

Single and soft

A

ToP

69
Q

Loud ( not single ) A2:

A

CoA or Ai

70
Q

What are extra heart sounds?

A
  1. S3
  2. S4
  3. Clicks
  4. Friction rub
71
Q

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

A

S3

72
Q

S3 + tachycardia

A

Gallop ( galloping horse)

73
Q

best heard with patient supine or in left lateral decubitus

increases by exercise, abdominal pressure or lifting legs

A

S3

74
Q

LV S3 is heard at ___________

RV S3 is hear at ____________

A

apex

LLSB

75
Q

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

A

S4 gallop

76
Q

S4 associiations are:

A

CHF

HCM

severe systemic HTN

Pulmonary HTN

myocarditis

tricuspid atresis

TAPVR

CoA

AS with severe LV disease

Kawasaki;s disease

77
Q

Usually pathologic

Snappy, high pitched sound usually in early sytole

Due to vibration in the artery distal to a stenotic valve

A

Click

78
Q

Click can be associated with:

A

valvar aortic stenosis or pulmonary stenosis

Truncus arteriosis

Pulmonary atresia/ VSD

Bicuspid aortic valve

Mitral Valve prolaps

Ebstein’s anomaly

79
Q

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

A

Friction rub

80
Q

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

A

Murmur

81
Q

When do murmurs occur?

A

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
82
Q

What is the first step in investigating a murmur

A

Identify the normal heart sounds ( S1 and S2 )

►

analyze the murmur

83
Q

Grading of intensity or loudness

A

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

84
Q

Murmurs are longer than heart sounds

HS can be distinguised by simultaneous palpation of the carotid arterial pulse

systolic, diastolic, continuos

A

Timing

85
Q

LOCATION

Area: UPPER RIGHT STERNAL BORDER ( 2nd RICS)

A

aortic stenosis, venous hum

86
Q

Upper left sternal border ( 2nd LICS)

A

Piulmonary stenosis

Pulmonary flow murmurs

Atrial septal defect

PDA

87
Q

Lower left sternal border ( 5th LICS)

A

Stiff’s murmur

ventricula septal defect

tricuspid valve regurgitation

hypertrophic cardiomyopathy

subaortic stenosis

88
Q

Apex ( 5th ICS LMCIS)

A

Mitral valve regurgiitation

89
Q

RAdiation:

To the neck?

axilla?

upper or lower sternal border

back

A

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

90
Q

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

A

blood flow

91
Q

Systolic ejection murmur ( AS vs MR vs VSD)

A

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

92
Q

Other characteristics:

shape

A

crescendo
decrescendo
up-down
plateau

93
Q

other charac:

pitch

A

high
mild
low

94
Q

other charac of murmurs

A

quality

blowing
harsh
rumbling
musical

95
Q

What are the variations in murmurs?

A

Variation with respiration ( R- sided murmurs change more tha n L- sided)

Variation with position of patient

variation with special maneuvers

96
Q

Definition:

contractio of ventricles

A

SYSTOLE

97
Q

contraction of atrium / relaxzaiton of ventricles

A

diastole

98
Q

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

A

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.

99
Q

backward flow thorugh the blood

A

regurgitation

100
Q

What are the types of murmurs

A

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
101
Q

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

A

Systolic ejection murmur

102
Q
  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)
A

Systolic ejection murmur

103
Q

What are the pathological systolic ejcetion murmur

A

B. Pathological

  1. ASD
  2. PS
  3. AS
104
Q
  • 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
A

Holosystolic/ pansystolic Murmur

105
Q
  • 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
A

holosystolic / pandiastolic murmur

106
Q
  • 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
A

continuos murmur

107
Q

What are the rechniques in enhancing auscultaion?

A
  • 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
108
Q

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

A

Muller’s maneuver

109
Q

standing to squatting- squattin increases stroke volume, and standing decreases it again

  • _________________ - as patient squats,this murmur should be decreased
A

Hypertrophic obstructive cardioyopathy

110
Q

occasionally decreases in standing to squatting

A

mitral regurgitation

111
Q

in squatting to standing this murmur increases

A

hypertrophic obstructive cardiomyopathy

Note: mitral regurgitation ocassionally increases

112
Q

mumur should decrease, as vLV increases and Lv enlarges

A
113
Q

place blood pressure cuff on both arms and occlude blood flow for 20 secs

Note: increases intensity : MR, VSD, other mumur unaffected

A

transient arterial occlusion

114
Q
  • 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
A

Arterial pulse

115
Q

Volume abnormalities:

quick upstroke and full voliume —> seen in HPN and anxxiety

A

hyperkinetic pulse

116
Q

Vvolime abnormalities:

  • a brisk pulse with large volume, collapsing pulse ( in aortic regurgitation)
A

Corrigans pulse

117
Q

Volume abnormalities:

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

A

pulse bisfiriens

118
Q

volume abnormalities:

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

A

pulse alterans

119
Q

Volume abnormalities:

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

A

pulse parodoxus

120
Q

How is pulse being graded?

A

0= no pulse

3= normal pulse

4= bounding pulse

121
Q

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

A

intermittent claudication

122
Q

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

A

Leriche’s syndrome

123
Q

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

A

takayasus’s arteritis

124
Q

What vein is used in Cenral venous pressure

A

Right internal jugular Vein is used

125
Q
A

2H. Physical Diagnosis (5 decks)

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