Peds PA exam 2 Flashcards
Physical Assessment of Head
Look for;
torticollis
examine from above, side, with fingertips, for sutures; Face: forehead and upper orbit, orbitonasal zygomatic area, maxillomand. area, posterior cranial vault
Macrocephaly Assessment
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
Causes of Microcephaly
Genetic defect Karyotype intrauterine infections antenatal radiation exposure to drugs/chemicals perinatal insult
Scaphocephaly/Dolichocephaly
positional problems in premies
Plagiocephaly
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
craniosynostosis
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
Brachycephaly
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
Crouzon’s Syndrome
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
Apert Syndrome
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.
Oxycephaly
closure of all sutures except squamosal
Lambdoidal Craniostosis
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
Alopecia Areata Vs Tinea Capitis
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
midface hypoplasia
assoc w sleep apnea & stridor
dental problems
maybe hearing problems
Micrognathia
mandible has not grown asm uch asit should-small mandible and chin
surgical advancement of mandible and chin via intraoral route
prognathic mandible
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
Sturge Weber Syndrome
non elevated purple venous malormation in distribution of trigeminal nerve, opthalmic division
high incidence of dev. delay
ocular complications like glaucoma on affected side
Parotiditis- Types & causes
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
Differential Diagnosis for Parotiditis
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
Myopia
when anterior-posterior diameter ofe eye is too long relative to refracting power of cornea and lens
hyperopia
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
Astigmatism
refractive eye error that causes blurred vision
when optical system of the eye ( cornea usually) is not perfectly spherical
strabismus
when eyes do not move in synchronous pattern
Esotropia
type of strabismus-inward deviation
exotropia
outward deviation, type of strabismus
latent strabismus
apparent only on dissociation of vvision of the eyes (covering one eye)
phoria-exophoria, esophoria, hyperphoria
hypertropia
misalignment of eyes (strabismus) whereby visual axis of one eye is higher than the fellow fixating eye
hypotropia
similar condition, focus being on the eye w/ visual axis lower than fellow fixating eye
Esophoria
tendency toward inward deviation of eye, usually b/c of extraocular muscle imbalance
exophoria
form of heterophoria-tendency of eye to deviate outward
comitant strabismus
same deviation in all fields of gaze
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
Causes of comitant strabismus
hereditary, familial predisposition
sensory deprivation
Accomodative- freqeuent convergence in children who are hypermetropic
Testing for Stabismus
hirschberg/corneal light red reflex/bruckner cover test evaluate extraocular movement binocular status-steropsis tests
Amblyopia
poor vision caused by abnormal dev secondary to abnormal visual stimulation
pressence of associated findings: strabismic amblyopia, anisometropic amblyopia, deprivational amblyopia
Strabismic amblyopia
results from abnormal binocular interaction
causes fovea of 2 eyes to be presented iwth different images
Anisometropic Amblyopia
fovea are also presented with different images r/t unequal refractive error
refractive amblyopia
most commonly in hyperopic patients, may occur in patients w myopia or astigmatism as well though
Deprivation amblyopia**
least common and most serious type of amblyopia***
severe visual deprivation due to occlusion of visual axis/distortion of foveal image
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
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
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
12mo-3years screening
the usual testing + at age 3, start vision screening using optotypes
Refer; who cannot read at least 20/40
4-5 years old screening
usual tests, instrument based screen plus using optotype
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
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
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
Cover Test
watch for flick movements of eye; small angle strabismus
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
Pupil Assessment
integrity dependes on intact iris, CN II and III, and sympathetic nerves innervating eye
Hippus
Normal pupil is continuous motion dilating in and out by small contractions
more prominent in pediatric patients exposed to bright light
Direct & conensual
direct- ipsilateral constriction
consensual- flash light in one eye and other pupil reacts
Aniscoria
Simple
0.4mm or more difference in size of R and L pupil not related to drugs, ocular injury to inflammation
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
Iris coloboma
isolated iris coloboma does not interfere w/ vision
Aniridia
absence of iris
1/3 associated w/ Wilm’s tumor
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
Ciliary Injection
injection at limbus!! Does not spare limbus
lessens as it moves to palpebral conjunctiva
seen in uveitis, keratitis, acute angle glaucoma
Chemosis
swelling of conjunctiva from allergic conjunctivitis and in kids w/ pharyngoconjunctival fever
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
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
Hyphema
blood between anterior chamber (space between the iris/cornea)
from trauma, blunt or penetrating; can be assoc w other eye injury
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
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
Conjunctivitis- Herpes
skin vesicles
corneal infection w “dendrite”- hallmark
Allergic Conjunctivitis
environmental allergen, seasonal, sneezing/congestion
Hallmark: ITCH
Blepharitis
eyelid inflammation/infection
cause- staph infection at lash base
skin oil glands inflamed
*lice can cause this!
Chalazion
obstructed meibomian gland
hyphema
layering of blood in anterior segment
hypopyon
pus in anterior segment
iridocyclitis
inflammation of iris
iridogonesis
quivering of iris when patient moves eye
synechia
adhesion between iris and cornea
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
Sensory Hearing Loss
damage of cochlea (outer hair cells or outer & inner hair cells)
mixed hearing loss
presence of both conductive and sensory impairment
neural hearing loss
damage to auditory neurons (spiral ganglia) and / or auditory branch of eith nerve. ex) auditory neuropathy and dysynchrony
central hearing loss
damage to auditory structures in brainstem, thalamo cortex/cortex.
Early Hearing loss causes
maternal rubella, CMV, genetic disorders causing malformation of cochlea, sepsis, o2 deprivation, hyperbillirubinemia
Medications-lasix, aminoglycosides, vanco
Genetic Syndromes associated with Hearing loss
Waardenburg: white forelock and eye abnormalities
Jerveil syndrome, Lange Nielson: deafness assoc w/ long QT –>sudden death! EKG!
Renal Abnormalities
kidneys and ears form at same time in utero;
Alport’s syndrome- hearing loss + hematuria
sensorineural hearing loss- screening
noise induced hearing loss
presbycusis
meiniere’s (more adults)
tumors of auditory nerve- Acoustic Neuroma causes sudden progressive loss
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
Brachial Cyst
*pseudomonas smell** distinct odor
Crouzon’s Ears
low, rotated backwards
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
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
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
Right Ear Landmarks placement
Short process of malleus: 1:30
Cone of light reflex: 5:00
Left ear Landmarks placement
Malleus: 10:30
cone of light reflex: 7:00
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
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
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
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
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
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)
Tx of Epitaxis
Digital pressure 10-15 min
Topical vasoconstrictor: Neo-synephrine, Nosebleed QR, Nasal Sponge
Bactroban TID /1 week
posterior bleed–>ENT consult
Oral Cavity Evaluation
Lips: moist, symmetry, color, breathing, philtrum shape
Buccal mucosa- color, lesion, koplik spots
Gums- color, swelling, bleeding
Tongue, Teeth, palate, pharynx
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
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
Peritonsillar Abscess
most common deep infection of neck
typical complication of tonsillitis
usually along the tonlsillar pillar; obstruction and infection of Weber gland
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
Goiter
enlargement of thyroid
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
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
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
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
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)
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
Reassuring Cervical lymph nodes
tender on PE
Worrisome/Malignant Lymph nodes
more than 2cm and firm and matted
ex) Epitrochlear on radial side of elbow- enlargement is never benign
Normal Sizes of Nodes
Cervical and axillary: up to 1 cm
inguinal: up to 1.5 cm
Epitrochlear: up to 0.5cm
> 2cm–>malignant!!
Shotty node
freely moveable along sternocleidomastoid anterior
Anterior triangle of neck
bound superirorily by mandibular border and extends along sternocleidomastoid muscle to mid line of neck: Reactive Adenopathy from infection
posterior triangle
enlargement of posteior nodes are 50% malignant adenopathy
-others aoften from lice; worrisome of no infection present
Reactive adenopathy
reaction to an infection in drainage area
ex) pharyngitis, otitis media, conjunctivitis (which causes swelling in preauricular node!)
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?)
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
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
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
Triplet Repeat Disorder
Trinucleotide repeats in certain genes
results may be interference of normal gene or gene product
ex) Fragile X, huntington,
Variable Penetrance
how gene is expressed; factors that influence the effect on particular genetic changes
VATERL Associations
Vertebral anomalies Anal atresia Cardiac anomalies Trachea-esophageal fistula Esophageal atresia Renal anomalies, dysplasia Limb anomalies Single umbilical artery (instead of 2)
CHARGE associations
C-coloboma H-heart defects A-atresia choanal R-retardation of growht and development G- genitourinary problems E-ear abnormalities
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
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
Brachycephaly
closure of bilateral coronal or lambdoidal sutures
asymmetrical head or face, flat occiput, fontanels too large or too small, overlapping sutures
Micrognathism
small mandible
retrognathism
receding mandible
prognathism
projection of jaw beyond forehead-jay leno
Ocular hypertelorism
Vs
Hypotelorism
widespread eyes
eyes are close together
normal- about one eye length between the 2
Telecanthus
lateral displacement of inner canthi causes more space between the eye and nose on one side than the other
fused eyebrow is associated with
cornelia de langue
Asymmetrical Crying Facies
higher incidence of congenital heart disease- VSD, ASD, PDA, Tet
What are different colors within one iris associated with?
retinal blastoma
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
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
Shallow philtrum associated with
Fetal alcohol syndrome
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
Myotonic Dystrophy
Myotonia- cannot relax the muscle, continuous contraction of the muscle
cheshire cat smile
appear with drooping eyes/face, muscle wasting, cataracts
syndactaly
joining of hte fingers or toes
clinodactyly
curved fingers
positive thumb sign
connective tissue disorder- thumb sticks hwen you make a fist out b/c its long, narrow, tapered
gynecomastia
enlarged male breast
pectus excavatum
sunken in chest
pectus carinatum
pigeon shaped chest, protrudes
ash leaf is associated with
tuberous sclerosis
Struge weber associated with
glaucoma and red mark on part of face
coloboma
abnormal pupil- can be retina or iris
cherry red spot in macula of retina is associated with
Tay Sach’s
Ectopia Lentis
displacement of lens- abnormal flat cornea, increased axial length of the globe, hypoplastic iris
seen in Marfan’s
rocker bottom feet are associated with
Trisomy 18
curved bottom foot
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
Cardiac Evaluation- HISTORY
exercise tolerancevery 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
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
Number one cause of myocarditis is
Enterovirus
Syncope + exercise=
Cardiomyopathy-NO SPORTS; electrical activity is affected
rapid breathing with SOB and colicky baby suggets
Heart Failure
BP is higher in the
legs
ALL THAT WHEEZES IS NOT ASTHMA
Lungs- if wheezing, could indicate cardiac problem
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
Bounding Pulse is a sign of __ and heard best __
Patent Ductus Arteriosis, heard at 2nd intercostal space under clavicle in pulmonic area
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
angle of louis
to the right-aortic space
to the left- pulmonic space
Situs inversus
complete anatomy reversal; cilia in nose brush thigns inward instead of out–>recurrent sinusitis
Kartegener Syndrome
reversal of cilia and is associated with transposition of great vessels
Auscultation ares
Aortic, mitral, Erb’s (common for innocent murmurs), Tricuspid, pulmnic
+infraclavicular- carotid and axillary
and posterior under sapula
What is heard best under scapula on posterior
Coarcation of aorta
what is heard best below clavicle
PDA
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
S1
closure of tricuspid and mitral valve
best heard at left lower sternal border or apex
splits in s1
can be norml in children but if are wide can be right bundle branch block/Ebstein anomaly
s2
closure of pulmonic and aortic valve
best heard at base of heart
if split varies with respiration, this is
abnormal
if there is no preop murmur, then there is a post op murmur
bleeding out!
Murmurs
produced when blood velocity because critically high in presence of narrowing or irregularity
leads to turbulence which produces a sound
pregnant women have murmurs because of
physiological anemia
Systolic Murmur
1) Ejection- short ejection murmur is common
2) holosystolic or reguritant
Diastolic Murmurs
Diastolic murmurs are never normal!!
1) early decrescendo
2) mid diastolic
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
Third Heart Sound
associated with ventricular filling
louder in noncompliant left ventricle
louder with increased BF/CO
intermittent s2 may be normal variant
Chest X-Ray- Tetrology of Fallot
BOOT sign
Chest Xray- transposition of great artiers
egg on a string sign
chest xray- pulmonary venous connection
snowman sign
chest xray- partial anomalous Pulmonary Venous Return
scimitar sign
5 Innocent Murmurs of childhood
Still's murmur Pulmonary flow murmur Peripheral pulmonic stenosis murmur Supraclavicular bruit Venous hum
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
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
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
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
Venous Hum
continuous supraclavicular right more than left disappears with head position change loudest sitting or standing
Wide Split S2 indicates
ASD
if PMI is at left of nipple
heart is possibly enlarged-should be on right
if BP is lower in the legs than arms, this indicates
coarcation of aorta- heard best on back below scapula
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
pulmonic stenosis
systolic ejection murmur
upper left sternal border
radiates to back
click at sternal border varies with respiration
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
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*
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
ASD
upper L sternal border
wide fixed split S1
subtle exercise intolerance
fatigue!
what causes diastolic murmurs?
turbulence in ventricular inflow- narrowing, increased flow, semilunar valve regurg
what causes continuous murmurs
abnormal systemic to pulmonary artery communications
PDA
AV fistula or coronary artery fistula
Abnormal Murmurs in first days of life
outflow obstruction murmurs: AS, PS, Coarc
abnormal communication: VSD, PDA
Why do infants present with tachycardia
the cannot increase stroke volume, so they increase the rate to increase output
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
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
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%
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
Aortic Dissection
Emergency
acute and sharp pain
anterior chest or back
Marfan Syndrome and Ehler’s Danlos
Pericarditis
severe substernal chest pain
won’t lean backward!!
pain is reproduced by sternal pressure
consider in post op cardiac pts
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
Kawasaki Disease
vasculitis, young children (
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!
