History and examination Flashcards
1
Q
What level of deoxygenated haemoglobin must there be to see cyanosis?
A
20g/L deoxygenated haemoglobin
2
Q
What are the paediatric causes of clubbing?
A
- Cardiovascular
- Congenital cyanotic heart disease
- Subacute infective endocarditis
- Respiratory
- Bronchiectasis
- Lung abscess
- Empyema
- Cystic fibrosis
- Pulmonary fibrosis
- Pulmonary haemosiderosis
- Gastrointestinal
- Inflammatory bowel disease
- Coeliac disease
- Biliary cirrhosis
- Miscellaneous
- Congenital
- Atrial myxoma
- Thalassaemia
- Hyperthyroidism
3
Q
What are the differentials for an ejection systolic murmur?
A
- Upper right sternal edge (carotid thrill): Aortic stenosis
- Upper left sternal edge (no carotid thrill): Pulmonary stenosis or ASD
- Mid/lower left sternal edge: Innocent murmur
- Long, harsh systolic murmur + cyanosis: Tetralogy of Fallot
4
Q
What are the differentials for a pansystolic murmur?
A
- Lower left sternal edge (+/- thrill): VSD
- Apex: Mitral regurgitation
- Lower left sternal edge (+/- cyanosis): Tricuspid regurgitation
5
Q
What are the differentials for a continuous murmur?
A
- Left infraclavicular (+/- collapsing pulse): PDA
- Infraclavicular (+ cyanosis + lateral thoracotomy): Blalock-Taussig shunt
- Any site (lungs, shoulder, head): Arteriovenous fistula
6
Q
What are the differentials for a diastolic murmur?
A
- Left sternal edge (+/- carotid thrill or VSD): Aortic regurgitation
- Median sternotomy (+/- PS murmur): Repaired tetralogy of Fallot
- Apical (+/- VSD): Mitral flow
7
Q
What are the 4 S’s of innocent murmurs?
A
soft, systolic, asymptomatic, left sternal edge
8
Q
What are the 5 systolic innocent murmurs?
A
- Still’s (vibratory) murmur
- Pulmonary flow murmur
- Pulmonary flow murmur of newborns/peripheral pulmonary arterial stenosis murmur
- Supraclavicular or carotid bruit
- Aortic flow murmur
9
Q
Features of Still’s vibratory murmur?
A
- Most common, unknown cause
- Possibly due to turbulent blood flow in the left or right ventricular outflow tract, or vibrations through pulmonary valve leaflets
- Most commonly detected in 3-6 year olds, rare in infants
- Low frequency, vibratory, grade 2-3/6
- Heard maximally in mid-left sternal border
- Intensity increases in supine position, may disappear with Valsalva manoeuvre
10
Q
Features of pulmonary flow murmur?
A
- Most common in adolescents, but also often heard in 8-14 year olds
- Exaggeration of normal ejection vibrations within the pulmonary trunk
- Grade 2-3/6, harsh, non-vibratory ESM head at the upper left sternal border
- Intensity increases when supine
11
Q
Features of pulmonary flow murmur of newborns/peripheral pulmonary arterial stenosis murmur?
A
- Often present in newborns, disappearing by 6 months
- Turbulent flow through narrowed left or right pulmonary artery
- Grade 1-2, low to medium pitched, early to mid systolic murmur
- Can extend past second heart sound
- Heard best in the back and axilla, louder when supine
- Follow up with repeat clinical examination, + echo and cardiology referral if persistent
12
Q
Features of supraclavicular/carotid bruit?
A
- May present at any age
- Turbulent blood flow through a large diameter aorta into a smaller carotid or brachiocephalic artery
- Early systolic murmur, grade 2-3/6
- Best heard in supraclavicular fossa or over the carotid arteries
13
Q
Features of aortic flow murmur?
A
- Secondary to various high output physiological states (e.g. anaemia, hyperthyroidism, fever) causing turbulent flow through the ventricular outflow tract and aorta
- Low grade, non-harsh systolic murmur best heard in the aortic auscultation area
14
Q
What is the one continuous innocent murmur?
A
Venous hum
15
Q
Features of venous hum murmur?
A
- Commonly audible at 3-6 years
- Turbulent flow through slightly angulated internal jugular veins, or through the SVC at the junction of the internal jugular and subclavian veins
- Continuous murmur which is more intense in diastole
- Best heard in the supra- and infraclavicular regions
- Heard only when upright and disappears when supine
- Can be obliterated by rotating the head or gently occluding the neck veins
