Peds PA exam 2 Flashcards
1
Q
Physical Assessment of Head
A
Look for;
torticollis
examine from above, side, with fingertips, for sutures; Face: forehead and upper orbit, orbitonasal zygomatic area, maxillomand. area, posterior cranial vault
2
Q
Macrocephaly Assessment
A
serial head measures measure parents head developmental hx transilluminate skull look for skeletal dysplasia listen for bruit look for sunset eyes signs of neurocutaneous disorder
3
Q
Causes of Microcephaly
A
Genetic defect Karyotype intrauterine infections antenatal radiation exposure to drugs/chemicals perinatal insult
4
Q
Scaphocephaly/Dolichocephaly
A
positional problems in premies
5
Q
Plagiocephaly
A
common with back head sleep position
no growth perpendicular to sagittal suture
bitemporal narrowing
cranial elongation in anterior-posterior direction
face will be pushed toward affected side
frontal bossing due to pressure on the occiput
ear on affected side will be forward
parallelogram shape
6
Q
craniosynostosis
A
rare-skull sutures close and bony plates of skull become fused too early in ilfe
develops while fetus is still in womb
1/2500 births
Sagittal suture closes prem.
Simple or isolated craniosynostosis or complex/syndromal
7
Q
Brachycephaly
A
b/l coronal or lambdoidal early
broad skull with short base and recessed lower forehead
brachy/turi/acrocephaly is associated with: Apert syndrome, Crouzon syndrome, Pfeifffer syndrome
8
Q
Crouzon’s Syndrome
A
craniosynostosis most often of coronal and lamboid, sutures
underdeveloped midface w/ receded cheekbones/bulging eyes
Ocular proptosis-which is prominence in eyes due to shallow orbits
Esotropia & wideset eyes
9
Q
Apert Syndrome
A
Ø Very high brachycephalic head Ø Severe syndactyly affecting all limbs. Ø Syndactyly involves bony fusion. Ø Apert is the second most common craniofacial syndrome after Crouzon.
10
Q
Oxycephaly
A
closure of all sutures except squamosal
11
Q
Lambdoidal Craniostosis
A
if there is lambdoidal synostis the head can’t expand in frontal region on affected side of the head, so the growth will be affected on unaffected side
growth restriction on affected side»overgrowth everywhere else
Trapezoid
12
Q
Alopecia Areata Vs Tinea Capitis
A
AA:
distrib: patchy, multifocal
onset: abrupt, waxes/wanes
appearance: thin w/ abrupt bare patches, exclamation point hairs
Degree of shed: prominent
age of onset: any, first before 20 usually
other: personal or fam hx of autoimmune, need TSH
Tinea Capitis:
distrib: specific area-focal or multifocal
onset: gradual or abrupt
appearance: none to some inflamm, scaling
age of onset: common in childhood, any
other: contact w/ animal w/ dermatophytes
13
Q
midface hypoplasia
A
assoc w sleep apnea & stridor
dental problems
maybe hearing problems
14
Q
Micrognathia
A
mandible has not grown asm uch asit should-small mandible and chin
surgical advancement of mandible and chin via intraoral route
15
Q
prognathic mandible
A
lower jaw is too prominent
occurs w/ congenital overgrowth of lower jaw
pahologic such as gigantism due to pituitary overgrowth and other tumors
ex) Jay leno
16
Q
Sturge Weber Syndrome
A
non elevated purple venous malormation in distribution of trigeminal nerve, opthalmic division
high incidence of dev. delay
ocular complications like glaucoma on affected side
17
Q
Parotiditis- Types & causes
A
Wind parotiditis: air forced into parotid duct with glandular swelling- when children learn to lay wind instrument or blow balloons
Viral causes: mumps, parainfluenza types 1 and 3, HIV, CMV, coxackie
Bacterial: staphylococcus aureus, streptococcus species
can have tender and red gland w/ significant systemic symptoms
18
Q
Differential Diagnosis for Parotiditis
A
recurrent parotiditis associated w/ pain & fever
abscess of parotid
rare: cat scratch, TB
metabolic: slow, progressive, painless, no inflammation
starvation-hypoproteinemia, anorexia, cushing
Obstructive enlargement-stones
Autoimmune: lupus w/ recurrent swelling as initial sign, sjogen syndrome
19
Q
Myopia
A
when anterior-posterior diameter ofe eye is too long relative to refracting power of cornea and lens
20
Q
hyperopia
A
eye is too short relative to refracting power of eye. focal point of image occurs posterior to retina and image that forms ont he retina is blurred
21
Q
Astigmatism
A
refractive eye error that causes blurred vision
when optical system of the eye ( cornea usually) is not perfectly spherical
22
Q
strabismus
A
when eyes do not move in synchronous pattern
23
Q
Esotropia
A
type of strabismus-inward deviation
24
Q
exotropia
A
outward deviation, type of strabismus
25
latent strabismus
apparent only on dissociation of vvision of the eyes (covering one eye)
phoria-exophoria, esophoria, hyperphoria
26
hypertropia
misalignment of eyes (strabismus) whereby visual axis of one eye is higher than the fellow fixating eye
27
hypotropia
similar condition, focus being on the eye w/ visual axis lower than fellow fixating eye
28
Esophoria
tendency toward inward deviation of eye, usually b/c of extraocular muscle imbalance
29
exophoria
form of heterophoria-tendency of eye to deviate outward
30
comitant strabismus
same deviation in all fields of gaze
31
incomitant strabismus
limited eye movement and size of deviation is different in different fields of gaze
most commonly where there is paralysis of one or more extraocular muscle
Neurological- lesions of 3rd 4th CN from trauma, tumor, infection, ICP
Muscular- direct involvement of muscles
Myasthenia gravis, congenital problems
32
Causes of comitant strabismus
hereditary, familial predisposition
sensory deprivation
Accomodative- freqeuent convergence in children who are hypermetropic
33
Testing for Stabismus
```
hirschberg/corneal light
red reflex/bruckner
cover test
evaluate extraocular movement
binocular status-steropsis tests
```
34
Amblyopia
poor vision caused by abnormal dev secondary to abnormal visual stimulation
pressence of associated findings: strabismic amblyopia, anisometropic amblyopia, deprivational amblyopia
35
Strabismic amblyopia
results from abnormal binocular interaction
| causes fovea of 2 eyes to be presented iwth different images
36
Anisometropic Amblyopia
fovea are also presented with different images r/t unequal refractive error
37
refractive amblyopia
most commonly in hyperopic patients, may occur in patients w myopia or astigmatism as well though
38
Deprivation amblyopia**
least common and most serious type of amblyopia***
| severe visual deprivation due to occlusion of visual axis/distortion of foveal image
39
Vision Screening
routine screening at age 18 been changed to a risk assessment
visual acuity screen is recommended at ages 4 and 5 years
instrument based screening to assess risk at ages 12 and 24 months
+ well visits at 3-5 years
40
0-6month old vision screening
ocular history
vision assessment
external inspection
ocular motility assessment-should fix and follow by 6months
pupil examination
red reflex exam- refer infants with abnormal red reflex or history of retinoblastoma in parent/sibling
41
6-12 month screening
ocular hx, external inspection, red reflex, pupil exam, ocular motility, visual acuity fixte and follow
wen to refer: infants with strabismus, w/ chronic tearing or discharge
who fail instrument based screen
42
12mo-3years screening
the usual testing + at age 3, start vision screening using optotypes
Refer; who cannot read at least 20/40
43
4-5 years old screening
usual tests, instrument based screen plus using optotype
44
over 5 years old screening
ocular hx, vision assessment, external inspection of eyes/lids, ocular motility assessment, pupil examination, red ref, visual acuity, + opthalmoscopy
Refer: who cannot read at least 20/32 w either eye; must identify majority of optoypes on 20/32 line and those not reading at grade level
45
Assessing for Ocular motility
3-6 feet in front of child
patient follow your giner w eyes- Double H
-check convergence- go in toward patient's nose
46
Hirschberg test
Negative: both reflexes are located .4mm nasal to center of pupil
Positive: if one reflex is located in a position other than .5mm nasal, suspect strabismus
47
Cover Test
watch for flick movements of eye; small angle strabismus
48
Bruckner/Red Reflex
darken room
adjust opthalmoscope so light is not TOO bright
dial to zero
use left hand and left eye to examine LEFT eye; right to right
have patient stare at point on wall
identifies strabismus as well as asymmetric refractive errors
Unequal refractive errors: reflexes will differ in brightness
49
Pupil Assessment
integrity dependes on intact iris, CN II and III, and sympathetic nerves innervating eye
50
Hippus
Normal pupil is continuous motion dilating in and out by small contractions
more prominent in pediatric patients exposed to bright light
51
Direct & conensual
direct- ipsilateral constriction
| consensual- flash light in one eye and other pupil reacts
52
Aniscoria
Simple
| 0.4mm or more difference in size of R and L pupil not related to drugs, ocular injury to inflammation
53
Relative Afferent Pupillary Defect/Marcus Gunn Pupil
most common pupil problems
occurs w/ significant optic nerve or retinal disease & when there's a difference in disease process between R and L eyes
In Marcus Gunn pupil, the pupil where the light is shined
will constrict strongly when light is shining into the eye
but as light moves to illuminate the abnormal eye, both pupils dilate (react as though the light was dimmer
l The eye that dilates when the light is shown on it, is the
abnormal or Marcus Gunn Pupil
54
Iris coloboma
isolated iris coloboma does not interfere w/ vision
55
Aniridia
absence of iris
| 1/3 associated w/ Wilm's tumor
56
Assessment of Red Eye
External inspection of eyes and lids- suspect orbital injury if eye is red at limbus (where iris meets sclera);
-ocular motility, pupil exam, vision screen
57
Ciliary Injection
injection at limbus!! Does not spare limbus
lessens as it moves to palpebral conjunctiva
seen in uveitis, keratitis, acute angle glaucoma
58
Chemosis
swelling of conjunctiva from allergic conjunctivitis and in kids w/ pharyngoconjunctival fever
59
Subconjunctival Hemorrhage
blood under conjunctiva
causes: trauma, sudden increase of pressure in chest
S&S: assoc w/ history of trauma
-if mild and no other sign of ocular injury- benign will disappear in 1 week, no tx
60
corneal abrasion
trauma, foreign body/chemical exposure
S&S:
sensitivity to light, extreme pain, trouble opening eye, tearing, foreign body sensation
dx: area of epithelial defect stains w fluorescein dye and lights up w/ blue light
61
Hyphema
blood between anterior chamber (space between the iris/cornea)
from trauma, blunt or penetrating; can be assoc w other eye injury
62
Conjunctivitis- bacterial
bacterial- H influ, staph, chlamydia
RED, purulent discharge* THE hallmark, swollen lid, one or both eyes
**antibiotic drops do NOT cure gonococcal conjunctiivitis- suspect gonorrhea and send to ER-need IV antibiotis
63
Viral Conjunctivitis
Adenovirus, Herpes simplex, zoster, molluscum contagiosum
S&S- irritation, light sensitivity, swollen lids, watery discharge, some mucous, NOT purulent (distinguishes from bacterial)
often enlarged tender lymph node is present in front of ear
64
Conjunctivitis- Herpes
skin vesicles
| corneal infection w "dendrite"- hallmark
65
Allergic Conjunctivitis
environmental allergen, seasonal, sneezing/congestion
| Hallmark: ITCH
66
Blepharitis
eyelid inflammation/infection
cause- staph infection at lash base
skin oil glands inflamed
*lice can cause this!
67
Chalazion
obstructed meibomian gland
68
hyphema
layering of blood in anterior segment
69
hypopyon
pus in anterior segment
70
iridocyclitis
inflammation of iris
71
iridogonesis
quivering of iris when patient moves eye
72
synechia
adhesion between iris and cornea
73
conductive hearing loss
impairment of outer and or middle ear conductive mechanism only; sound does not make it past the TM. ex) wax build up, foreign object
Screening; Eustachian tube dysfunction, ear fluid, hole in eardrum, fixed middle ear bone
74
Sensory Hearing Loss
damage of cochlea (outer hair cells or outer & inner hair cells)
75
mixed hearing loss
presence of both conductive and sensory impairment
76
neural hearing loss
damage to auditory neurons (spiral ganglia) and / or auditory branch of eith nerve. ex) auditory neuropathy and dysynchrony
77
central hearing loss
damage to auditory structures in brainstem, thalamo cortex/cortex.
78
Early Hearing loss causes
maternal rubella, CMV, genetic disorders causing malformation of cochlea, sepsis, o2 deprivation, hyperbillirubinemia
Medications-lasix, aminoglycosides, vanco
79
Genetic Syndromes associated with Hearing loss
Waardenburg: white forelock and eye abnormalities
| Jerveil syndrome, Lange Nielson: deafness assoc w/ long QT -->sudden death! EKG!
80
Renal Abnormalities
kidneys and ears form at same time in utero;
| Alport's syndrome- hearing loss + hematuria
81
sensorineural hearing loss- screening
noise induced hearing loss
presbycusis
meiniere's (more adults)
tumors of auditory nerve- Acoustic Neuroma causes sudden progressive loss
82
External Assessment
shape, size, (large: fragile x), symmetry, variations frmo normal
presence of dimples, tags, nodules: remnant of first brachial cleft
position of ear- rotated? should be along straight plan with outer canthus of eye
swelling, drainage, erythema, enlarged pre/post auricular nodes, external otitis w/ cellulitis causes ear to protrude
83
Brachial Cyst
*pseudomonas smell** distinct odor
84
Crouzon's Ears
low, rotated backwards
85
External Otitis Media
r/t changes in pH of ear canal
pseudomonas most common
Swimming*- "swimfree" in ears to dry canal
pain on movement of auricle; canal may be red, friable, pus
inspect entire TM for landmarks, color, contour, perforations
tenderness on palpation of tragus is indicative!
tx: antibiotics DROPS (100x stronger) not systemic
86
Otorrhea
otitis externa
alteration in acidic pH leads to susceptibility of microbial invasion, severe pain, "fullness" feeling in ear
r/t excessive moisture or cleaning, bacterial, viral, or fungal
87
Tympanic Membrane- What to look for
Color- red
| Landmarks: are they in the right place? Malleus, borders of TM, light reflex, presence of perforation or fluid
88
Right Ear Landmarks placement
Short process of malleus: 1:30
| Cone of light reflex: 5:00
89
Left ear Landmarks placement
Malleus: 10:30
| cone of light reflex: 7:00
90
Color of TM/Significance
Amber: serous fluid
blue or deep red: blood in middle ear
chalky white- thick TM indicates recurrent infection
Red- infection,
Dullness- fibrosis
white areas- healed perforations or inflammation or tubes
air bubbles: indicate middle ear fluid
91
Mastoiditis-
bacterial infection of mastoid air cells
accumulation of purulent exudate in middle ear- does not drain through ET or perforated TM but instead spreads through to mastoid bone
air cells are destroyed-->progression to coalescent phase: refer to ENT
92
Acute Otitis media organisms
bacterial: H influenzae- #1 organism for otitis media
S pneumonia-->meningitis/brain abscess
Group A strep,
Viral: RSV, influenza, mycoplasma pneumonia, fungai
93
Tympanogram: A, B, C
Documents Retraction of eardrum
Type A: Normal eardrum movement; -150 to 150 (?)
Type B: indicates little or no eardrum movement, suggesting fluid in middle ear
Type C: middle ear with negative pressure r/t retraction or blockage of ET
94
Nasal Mucosa/Secretions- Color and indications
Red inflamed; infection
pale boggy: allergy
Swollen grayish: chronic rhinitis
Purulent secretion:- high up, sinus infection
water secretions indicate: allergy, cold, elicit drug use, rarely skull fracture nasal infections
Foul smelling: FOREIGN BODY
95
Epitaxis
typically anterior in origin in childhood; Kiesselbach's area/plexus
Causes- trauma, inflammation (uri), anatomic (dev septum), vascular abnormalities (hemangioma), malignant neoplasm- (rhabdomyosarcoma, lymphoma), platelet dysfunction (nsaid use, ITP, leukemia, coagulopathy (hemophilia, von willebrand, liver disease), benign masses (granuloma, papilloma)
96
Tx of Epitaxis
Digital pressure 10-15 min
Topical vasoconstrictor: Neo-synephrine, Nosebleed QR, Nasal Sponge
Bactroban TID /1 week
posterior bleed-->ENT consult
97
Oral Cavity Evaluation
Lips: moist, symmetry, color, breathing, philtrum shape
Buccal mucosa- color, lesion, koplik spots
Gums- color, swelling, bleeding
Tongue, Teeth, palate, pharynx
98
Tonsillar Eval
| Grading
tonsils enlarge to peak size at 7; then they disappear slowly
Grading:
1+: visible only slightly beyond pillars
2+ if they are midway between pillars and uvula
3+: if are nearly touching uvula
4+: touching midline and occluding view of midline
99
Clinical Presentation of Streptococcal Tonsillitis
Nausea, fever maybe only presenting symptom
always examine throat of a child w abdominal pain, esp on right side b/c you can get lymphoid tenderness in right lower quadrant pain
epigastric tenderness and headache are other signs
Scarlet Fever- Pastia's lines, rash, untreated strept-->toxin causes scarlet fever
100
Peritonsillar Abscess
most common deep infection of neck
typical complication of tonsillitis
usually along the tonlsillar pillar; obstruction and infection of Weber gland
101
Sinuses
Maxillary: Present at birth; rapid growth from birth-4 years and then 6-12
Frontal- last to develop
Ethmoid- present at birth but not developed, grow during first 4 years, fully by 12
Sphenoid- underdeveloped at birth, doesnt grow til after 5
102
Goiter
enlargement of thyroid
103
thyroid nodules
nodules in children need referral to endocrine to see if need to biopsy; more often in females
some have higher risk of cancer, esp if history of radiation therapy --risk of thyroid disease
104
cystic hygroma
1 in 12,000 births
multioculated cystic lymphatic malformation usually found by age 2
2:1 left sided
discrete, soft, mobile, nontender, in posterior triangle
can cause trachial compression and stridor-->airway
usually dx in utero-->ENT consult
collection of lymph sacs with clear, colorless fluid
late presentations often follow viral infection
105
Second Brachial Cleft Cyst
most common congenital neck mass-2-3%
smooth, n/t, fluctuant masses occur along lower 1/3 of anteromedial border of sternocleidomastoid
"pencil point," protruding from lower part of sternoclidomastoid
can get infected-->must be removed
106
Thyroglossal Duct Cyst
usually below level of hyoid bone in midline or off center
seen best when neck is hyperextended
may rise with tongue protrusion and swallowing b/c can be connected to base of tongue, or connected to diaphragm
assoc w high incidence of thyroid carcinoma in adulthood
must be removed- can be only thyroid tissue so sometimes will develop hypothyroidism after removal
107
lymphadenopathy
enlargement of lymph nodes by proliferation of normal cells or infiltration of abnormal cells
-less common than localized adenititis
sign of underlying infection or systemic disease
Major causes
Medications (Cephecor)
Malignancy
autoimmune (juvenile arthritis, lupus)
108
anatomy of lymph node
bean shaped
covered with capsule
2 basic parts:
cortex- populated with lymphocytes- B and T cells and
Medulla- made up of macrophages
109
Reassuring Cervical lymph nodes
tender on PE
110
Worrisome/Malignant Lymph nodes
more than 2cm and firm and matted
| ex) Epitrochlear on radial side of elbow- enlargement is never benign
111
Normal Sizes of Nodes
Cervical and axillary: up to 1 cm
inguinal: up to 1.5 cm
Epitrochlear: up to 0.5cm
> 2cm-->malignant!!
112
Shotty node
freely moveable along sternocleidomastoid anterior
113
Anterior triangle of neck
bound superirorily by mandibular border and extends along sternocleidomastoid muscle to mid line of neck: Reactive Adenopathy from infection
114
posterior triangle
enlargement of posteior nodes are 50% malignant adenopathy
| -others aoften from lice; worrisome of no infection present
115
Reactive adenopathy
reaction to an infection in drainage area
| ex) pharyngitis, otitis media, conjunctivitis (which causes swelling in preauricular node!)
116
Lymphadenitis
the node itself is infected
inflamed, enlarged, tender
acute onset
associated with tender erythematous warm lymph nodes and fever
need ultrasound to see if it needs to be drained (is there an abscess?)
117
Cleidocraniodyostosis
no collar bones or abnormally developed; jaw and brow protrudes, wide nasal bridge (shoulders touch together in front of body); delayed closure of fontanelles
118
Blaschkow's lines
pigment differences between the front and back
| inoontinenti pigmenti- swirls on the skin- can be swirls in brain as well that can lead to seizures
119
Single Gene Disorder
mutation in single gene causes a disorder
Ex) Marfan, neurofibromatosis (DOMINANT)
ex) CF, sickle cell, tay sach (RECESSIVE)
X linked- Duchenne Muscular Dystrophy
Testing: Micro array, DNA sequencing, deletion testing
120
Triplet Repeat Disorder
Trinucleotide repeats in certain genes
results may be interference of normal gene or gene product
ex) Fragile X, huntington,
121
Variable Penetrance
how gene is expressed; factors that influence the effect on particular genetic changes
122
VATERL Associations
```
Vertebral anomalies
Anal atresia
Cardiac anomalies
Trachea-esophageal fistula
Esophageal atresia
Renal anomalies, dysplasia
Limb anomalies
Single umbilical artery (instead of 2)
```
123
CHARGE associations
```
C-coloboma
H-heart defects
A-atresia choanal
R-retardation of growht and development
G- genitourinary problems
E-ear abnormalities
```
124
Goldenhar Symdrome
affects one side of the face only
partially formed or absent ear (microtia)
chin maybe closer to affected ear; one corner of mouth may be higher; benign growths of eye, missing eye
other: cleft lip/palate, hearing loss, vertebral anomalies, kidney/heart problems***
missing dentition, lack of facial development
125
Minor Anomaly
occurs in less than 4% of population most often in face and hands
normal phenotypic variant is > 4%
ex) crease in asian children
But can be associated as markers for occult major malformations** ex) sacral tuft or dimpling- spina bifida
specific minor abnormalities of face hands and feet- Down's
3 or more minor anomalies increased risk of major malformation
126
Brachycephaly
closure of bilateral coronal or lambdoidal sutures
| asymmetrical head or face, flat occiput, fontanels too large or too small, overlapping sutures
127
Micrognathism
small mandible
128
retrognathism
receding mandible
129
prognathism
projection of jaw beyond forehead-jay leno
130
Ocular hypertelorism
Vs
Hypotelorism
widespread eyes
eyes are close together
normal- about one eye length between the 2
131
Telecanthus
lateral displacement of inner canthi causes more space between the eye and nose on one side than the other
132
fused eyebrow is associated with
cornelia de langue
133
Asymmetrical Crying Facies
higher incidence of congenital heart disease- VSD, ASD, PDA, Tet
134
What are different colors within one iris associated with?
retinal blastoma
135
Palpebral Fissures
normal: horizontal or upword with an angle of less than 10 degrees
Upward is > 10 degrees
downward: external canthus is lower than internal
136
Wilson Disease
Kayser fleischer rings- deposition of copper in cornea; brownish/greenish ring
severe liver cirrhosis, neurlogical symptoms, psych symptoms
Do a serulomplasim
Copper metabolism disorder
urine test, blood test, liver function
137
Shallow philtrum associated with
Fetal alcohol syndrome
138
Waardenburg Syndrome
| 5 major diagnostic criteria
1) Sensorineural hearing loss
2) Iris pigmentary abnormality (two eyes diff color or iris bicolor or brilliant blue iris)
3) hair hypopigmentation (forelock or white hairs elsewhere)
4) Dystopia canthorum (lateral displacement of inner canthi)
5) first degree relative with Waardenburg
Minor criteria- beak nose, hypoplasia nasi, premature graying of hair, medial eyebrow flare
139
Myotonic Dystrophy
Myotonia- cannot relax the muscle, continuous contraction of the muscle
cheshire cat smile
appear with drooping eyes/face, muscle wasting, cataracts
140
syndactaly
joining of hte fingers or toes
141
clinodactyly
curved fingers
142
positive thumb sign
connective tissue disorder- thumb sticks hwen you make a fist out b/c its long, narrow, tapered
143
gynecomastia
enlarged male breast
144
pectus excavatum
sunken in chest
145
pectus carinatum
pigeon shaped chest, protrudes
146
ash leaf is associated with
tuberous sclerosis
147
Struge weber associated with
glaucoma and red mark on part of face
148
coloboma
abnormal pupil- can be retina or iris
149
cherry red spot in macula of retina is associated with
Tay Sach's
150
Ectopia Lentis
displacement of lens- abnormal flat cornea, increased axial length of the globe, hypoplastic iris
seen in Marfan's
151
rocker bottom feet are associated with
Trisomy 18
| curved bottom foot
152
Location of PMI
Should be at 5th intercostal space, right of nipple line
if it is on the left of the nipple, can be a large heart
153
Cardiac Evaluation- HISTORY
exercise tolerance***very important- fatigue is sign of low ejection fraction
feeding difficulty
dizziness or syncope
perinatal history
Maternal History***
use of NSAIDS or ASA cause premature closure of ductus arteriosis
Use of Lithium leads to tricuspid valve anomaly
DM- Cardiac renal anomalies
Alcohol and drug use- VSD, ASD
154
Teratogens and Heart disease & malformations
```
Alcohol- 25-30%CHD and ASD,VSD, PDA
Lithium-10% CHD, Ebstein, ASD
Rubella 35% CHD, PPS, PDA, VSD, ASD
Maternal DM- 3-5% CHD? 30-5)%
Lupus- 50% CHD, assoc w HEART BLOCK
```
155
Number one cause of myocarditis is
Enterovirus
156
Syncope + exercise=
Cardiomyopathy-NO SPORTS; electrical activity is affected
157
rapid breathing with SOB and colicky baby suggets
Heart Failure
158
BP is higher in the
legs
159
*ALL THAT WHEEZES IS NOT ASTHMA*
Lungs- if wheezing, could indicate cardiac problem
160
Assessment and Pulse
pulse rate increase by 10-15bmp for each degree of fever
| Premature babies have bounding pulses because of lack of subcut fat and higher incidence of PDAs
161
Bounding Pulse is a sign of __ and heard best __
Patent Ductus Arteriosis, heard at 2nd intercostal space under clavicle in pulmonic area
162
Palpation technique for thrill
turn child to left and feel at apex
basal thrills felt with child sitting up
thrills- look at PMI and suprasternal notch
high frequency thrills along left border- VSD
low frequency thrill in 2nd ICS-aortic stenosis
Diastolic Thrill at apex- Mitral stenosis
163
angle of louis
to the right-aortic space
| to the left- pulmonic space
164
Situs inversus
complete anatomy reversal; cilia in nose brush thigns inward instead of out-->recurrent sinusitis
165
Kartegener Syndrome
reversal of cilia and is associated with transposition of great vessels
166
Auscultation ares
Aortic, mitral, Erb's (common for innocent murmurs), Tricuspid, pulmnic
+infraclavicular- carotid and axillary
and posterior under sapula
167
What is heard best under scapula on posterior
Coarcation of aorta
168
what is heard best below clavicle
PDA
169
7 S's of innocent Murmurs
1) Systolic
2) Short duration (not holosystolic)
3) single (no clicks or gallops)
4) small ( does not radiate)
5) sensitive (tend to change with position or respiratory effort- louder supine)
6) soft
7) sweet- no harsh sounds
170
S1
closure of tricuspid and mitral valve
| best heard at left lower sternal border or apex
171
splits in s1
can be norml in children but if are wide can be right bundle branch block/Ebstein anomaly
172
s2
closure of pulmonic and aortic valve
| best heard at base of heart
173
if split varies with respiration, this is
abnormal
174
if there is no preop murmur, then there is a post op murmur
bleeding out!
175
Murmurs
produced when blood velocity because critically high in presence of narrowing or irregularity
leads to turbulence which produces a sound
176
pregnant women have murmurs because of
physiological anemia
177
Systolic Murmur
1) Ejection- short ejection murmur is common
| 2) holosystolic or reguritant
178
Diastolic Murmurs
Diastolic murmurs are never normal!!
1) early decrescendo
2) mid diastolic
179
Grading Murmurs
1/6: Faint, not easily heard; comes after a few seconds
2/6: faint but heard immediately
3/6: loud but no thrill
4/6: loud with thrill
5/6: loud with thrill and herd at edge of stethoscope on chest
6/6 heard with stethoscope 1cm off chest wall
180
Third Heart Sound
associated with ventricular filling
louder in noncompliant left ventricle
louder with increased BF/CO
intermittent s2 may be normal variant
181
Chest X-Ray- Tetrology of Fallot
BOOT sign
182
Chest Xray- transposition of great artiers
egg on a string sign
183
chest xray- pulmonary venous connection
snowman sign
184
chest xray- partial anomalous Pulmonary Venous Return
scimitar sign
185
5 Innocent Murmurs of childhood
```
Still's murmur
Pulmonary flow murmur
Peripheral pulmonic stenosis murmur
Supraclavicular bruit
Venous hum
```
186
Still's murmur
froo uniform periodic vibration of left heart structure
first heard during sick visit in preschool, disappears by puberty
most common innocent murmur***
soft, twangy sound, vibratory,
lower Left sternal border
louder supine
decreases significantly or disappears with Valsalva
3-7year olds*
187
Pulmonary Ejection Flow murmur
```
15%
11-13 year olds most commoonly
short, systolic ejection
upper Left sternal
louder with expiration*
Normal S2 split
thin, tall bodies
straight back
increase CO
increases with supine position
increases with fever, anemia; varies from 1-3/4 grade
best heard supine with exhalation
```
188
Peripheral pulmonic branch stenosis
*neonates!
usually disappears by 6months
--if it does not disappear, is assoc with Williams syndrome and congenital rubella
newborn infants, well child visits heard in axillary
189
Supraclavicular Carotid Bruit
turbulence at take off area of brachiocephalic and carotid arteries from aortic arch
systolic and ejection, HIGH pitched, Harsh
does not radiate
best heard supraclavicular fossa on right
when you hyperextend shoulders-it goes away
190
Venous Hum
```
continuous
supraclavicular
right more than left
disappears with head position change
loudest sitting or standing
```
191
Wide Split S2 indicates
ASD
192
if PMI is at left of nipple
heart is possibly enlarged-should be on right
193
if BP is lower in the legs than arms, this indicates
coarcation of aorta- heard best on back below scapula
194
Aortic stenosis
5% of children with CHD
may also have coarct, VSD or PDA
non obstructive, isolated bicuspid aortic valve is most common congenital defect, 1% of population
presents: murmur, loud
can be valvar, sub or supra valvar
195
pulmonic stenosis
systolic ejection murmur
upper left sternal border
radiates to back
click at sternal border varies with respiration
196
PDA Presentation
should close within 48 hours
blood from right ventricle into descending aorta, bypasses lungs
direction of shunting depends on differential resistance between aorta and pulmonary artery
```
Prematurity-pulmonary overcirculation and present early
infants and kids can be asymptomatic
single s2= pulmonary HTN
Wide Pulse Pressure*
Bounding Pulses*
Quincke pulse on finger tips
Large PDA + ASD-->STROKE risk
```
197
coarctation of aorta
narrowing of aortic arch adjacent to ducturs
heard below left scapula**
decreases pulse and BP in lower extremities
often assoc w bicuspid aortic valve
can be pre or post ductal
HTN, heart failure and FTT without repair*
198
VSD
holosystolic murmur
high pithed, harsh if it is small
Diastolic rumble at apex
increased work of breathing , inc LA pressure, pulmonary edema, poor growth
leads to pulm HTN if unfound
must repair by age 1
can have normal-wide split S2 will vary with respirations
increase volume traversing pulmonary valve, causes it to close later
loudness of murmur does not correlate with size of defect
199
ASD
upper L sternal border
wide fixed split S1
subtle exercise intolerance
fatigue!
200
what causes diastolic murmurs?
turbulence in ventricular inflow- narrowing, increased flow, semilunar valve regurg
201
what causes continuous murmurs
abnormal systemic to pulmonary artery communications
PDA
AV fistula or coronary artery fistula
202
Abnormal Murmurs in first days of life
outflow obstruction murmurs: AS, PS, Coarc
abnormal communication: VSD, PDA
203
Why do infants present with tachycardia
the cannot increase stroke volume, so they increase the rate to increase output
204
Hypertrophic Cardiomyopathy**
| What maneuvars increase intensity of this murmur?
listen while squatting and then have them stand; murmur will INCREASE in intensity with standing!
-strain of valsalva decreases preload
exercise increase contractility
standing suddently decreases afterload
--->>increase intensity of hypertrophic mumur
205
What maneuvers will decrease the intensity and duration of this movement? Opposite of what you'd think!
Squatting or hand grasp- DECREASES murmur
| Raising legs- Decreases murmur
206
Chest Pain in children- differential dx
Musculoskeletal-costochondritis, pain with deep breath
Respiratory conditions- cough, PE, OCP use? leg trauma
Psychogenic- anxiety
GI disorders- GERD, foreign body, hiatal hernia
Cardiac Disease-myocardial ischemia, anomalies, see card
Idiopathic-20-45%
207
chest pain- cardiac disease causes
```
Myocardial ischemia- coronary anomalies
Kowasaki
cocaine, drugs
arrythmias
hypertrophic cardiomyopathy
marfan- aortic dissection!
Pericarditis- pt will not lean backward, want to learn forward
```
208
Aortic Dissection
Emergency
acute and sharp pain
anterior chest or back
Marfan Syndrome and Ehler's Danlos
209
Pericarditis
severe substernal chest pain
won't lean backward!!
pain is reproduced by sternal pressure
consider in post op cardiac pts
210
When to refer chest pain
with or after exercise, with syncope or near syncope, pain in patient with previous cardiac disease or surgery, or acute, sudden onset in marfan's
211
Kawasaki Disease
vasculitis, young children (
212
Kawasaki Disease Dx
Fever for at least 5 days
and at least 4/5 features:
1) changes in extremities-edema, erythema, desquamation
2) Polymorphous exanthem, usually truncal
3) Conjunctival injection that SPARES LIMBUS
4) Erythema and/or fissuring of lips and oral cavity
5) Cervical lymphadenopathy
and illness cannot be explained by other disease process
can have strawberry tongue
peeling hands!
