cardiologic diagnosis
DESCRIPTION
CARDIOLOGIC DIAGNOSIS. I.U. Cerrahpaşa Medical Faculty Department of Pediatrics Division of Pediatric Cardiology. Prof. Dr. Ayşe Güler EROĞLU. SUBJECTS. History Physical examination Inspection Palpation Oscultation Innocent murmurs Electrocardiogram Telecardiogram. HISTORY. - PowerPoint PPT PresentationTRANSCRIPT
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CARDIOLOGIC DIAGNOSIS
I.U. Cerrahpaşa Medical Faculty
Department of Pediatrics
Division of Pediatric Cardiology
Prof. Dr. Ayşe Güler EROĞLU
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SUBJECTS
History Physical examination
Inspection Palpation Oscultation
Innocent murmurs Electrocardiogram Telecardiogram
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HISTORY
Sweating Exercise intolerance Common respiratory tract infections Growth retardation Feeding difficulties Palpitation Dyspne Cyanosis Chest pain Syncope
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HISTORY
Medical history (ilnesses, medications) Prenatal history (ilnesses, medications) Natal history (asphyxia, prematurity, birth
weight) Family history (CHD, sudden death, ARF) Mother’s health (DM,SLE)
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PHYSICAL EXAMINATION
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INSPECTION
General appearance Chromosomal, hereditary, nonhereditary
syndroms Pallor Cyanosis Clubbing Neck vein distension Left precordial bulge
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PALPATION
Pulses Volume Rate Rhythm Character
Chest Apical impulse
In newborn and infants 4. intercostal space/midclavicular line In older children and adults 5. intercostal space/midclavicular line
Precordial activity Thrills
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VOLUME OF PULSES
Increase in pulse volume: pyrexia, fever, anemia, exercise and thyrotoxicosis
Weak pulses: low cardiac output (left heart obstructive lesions: aortic valve atresia or stenosis
Bounding pulses: patent ductus arteriosus, aortic regurgitation, large systemic arteriovenous fistula
Differences in pulse volume between extremities: coarctation of the aorta
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BLOOD PRESSURE MEASUREMENT
The width of the cuff’s bladder should be 125%-155% of the diameter of the extremity.
The air bladder should be long enough to completely or almost encircle the limb.
The point of first appearance of Korotkoff sounds (phase I) shows the systolic blood pressure. The point of muffling is closer to the true diastolic pressure than the point of disappearance in children.
Even when a wider cuff is selected for the thigh, the systolic pressure in the thigh is 10-20 mmHg higher than that obtained in the arm.
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OSCULTATION
Heart rate and rhythm Heart sounds Other sounds Murmurs
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HEART SOUNDS First heart sound (S1): The S1 is associated with
closure of the atrioventricular valves (mitral and tricuspid) It corresponds to the beginning of systole. Abnormally wide splitting: right bundle branch
block, Ebstein’s anomaly Increased S1: pyrexia, anemia, excitement,
thyrotoxicosis, short PR interval, mitral stenosis
Decreased S1: long PR interval and mitral regurgitation
Second heart sound (S2): The S2 is associated with closure of semilunar valves (aortic and pulmonary). It corresponds to the beginning of diastole. In every normal child, the s2 is split during inspiration and single during expiration (normal splitting of the S2).
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HEART SOUNDS Widely split S2
Right ventricle volume overload: ASD, partial anomalous pulmonary venous return)
Right ventricle pressure overload: pulmonary stenosis
Delay in electrical activation of right ventricle: right bundle branch block
Early aortic valve closure: mitral regurgitation Narrowly split S2
Pulmonary hypertension Aortic stenosis
Paradoxically split S2
Severe aortic stenosis Left bundle branch block
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HEART SOUNDS
Single S2
Only one semilunar valve is present: aortic or pulmonary atresia, persistent truncus arteriosus
P2 is not audible: transposition of the great arteries, tetralogy of Fallot, severe pulmonary stenosis
Aortic closure is delayed: severe aortic stenosis
P2 occurs early: pulmonary hypertension P2 increases in pulmonary hypertension and
decreases in severe pulmonary stenosis, tetralogy of Fallot and tricuspid stenosis
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HEART SOUNDS Third heart sound (S3): The S3 is a low-frequency
sound in early diastole and is related to rapid filling of the ventricle. It is commonly heard in normal children and
young adults. A loud S3 is abnormal and is audible in large
shunt VSD, congestive heart failure. Fourth heart sound (S4): The S4 is a low-frequency
of late diastole and is rare in infants and children. It is always pathologic. It is seen in conditions with decreased
ventricular compliance.
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OTHER SOUNDS Ejection clic: It follows the S1 very closely,
therefore it sounds like a splitting of the S1 Valvular aortic and pulmonary stenosis, dilated
great arteries Midsystolic click with or without late systolic
murmur Mitral or tricuspid valve prolapse
Opening snup: It occurs earlier than the S3 during diastole Mitral or tricuspid stenosis
Pericardial friction rub (frotman) Pericarditis
Pericardial knock Constrictive pericarditis
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CHARACTERISTICS OF HEART MURMURS
Location
Intensity Quality
Radiation
Timing
Murmur
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TIMING OF HEART MURMURS
Murmurs
Systolic Continuous Diastolic
Ejection(Diamond Crescendo-
decrescendo)
EarlyRegurgitant(HolosistolicPansistolic)
Late Early Middiastolic Late
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Sistolic ejektion murmurs(Diamond shaped,
crescendo-decrescendo)
Aortic stenosis Pulmonary stenosis Increased flow in aorta Increased flow in pulmonary artery
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Sistolic regurgitant murmurs(Holosistolic, pansistolic)
Ventricular septal defect Mitral regurgitation Tricuspid regurgitation
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Early diastolic murmurs(Decrescendo)
Aortic regurgitation Pulmonary regurgitation
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Middiastolic murmurs(Flow murmurs)
Increased flow across the atrioventricular valves in patients with ASD, VSD, PDA
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Late diastolic murmurs(Presistolik)
Mitral valve stenosis Tricuspid valve stenosis
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Continuous murmurs
Arterial PDA Coronary artery
fistula Pulmonary AV fistula Sistemic AV fistula
Venous Venous ham
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Venous hum
A common innocent murmur is heard in healthy chidren at 2-8 years old
It is audible in the upright position The infraclavicular region, unilaterally or bilaterally The murmurs intensity changes with the position of
the neck and compression of cervical veins
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LOCATION OF HEART MURMURS
Aortic area: right parasternal 2. intercostal space
Pulmonary area: left parasternal 2. intercostal space
Tricuspid area: left parasternal 4.-5. intercostal space
Mitral area (cardiac apex): 5.-6.intercostal space/ midclavicular line
Mezocardiyak area (second aortic area, Erb): left parasternal 3.-4. intercostal space
Aorta Pulmonary
TricuspidMitral
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INTENSITY OF HEART MURMURS
Graded from 1 to 6. Grade 1: Barely audible. Grade 2: Soft, but easily audible. Grade 3: Moderately loud, but no accompanied
with a thrill. Grade 4: Louder and associated with a thrill. Grade 5: Audible with the stethescope barely on
the chest. Grade 6: Audible with the stethoscope off the
chest.
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INNOCENT MURMURS
Innocent murmurs are heard in up to 70-85 % of normal children at some time or another. They are musical, low- frequency, systolic ejection and a lower grade than 3/6 in intensity. The intensity of the murmur increases during febrile ilness or excitement, after exercise or in anemic states. 1. Still murmur: It is heard best with the patient supine and at the mid-point
between the left sternal border and the apex. This murmur may be confused with the murmur of VSD or mild mitral regurgitation.
2. Pulmonary flow murmur of children: It is common in children and adolescents. It is heard maximally at upper left sternal border. This murmur may be confused with the murmur of pulmonary valvular stenosis or ASD.
3. Pulmonary flow murmur of newborn: This murmur is commonly present in newborns, especially in premature infants. It is heard best at the upper left sternal border and transmits to the right and left chest, both axilla and the back. Theories of its origin include the relative small size of the branch pulmonary arteries after birth. It usually disappears by six months of age.
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TELECARDIOGRAM
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IS THE ROENTGENOGRAPHY APPROPRIATE
IS TELECARDIOGRAM OR NOT 1)The distance between the patient and the tube
should be 180 cm. 2)Postero-anterior 3)Standing.
HOW IS QUALITY 1)X-ray dosing Inspiration Symmetry
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Thymus
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INTERPRETING THE CHEST ROENTGENOGRAM
1)Heart size 2)Heart silhouette 3)Pulmonary vascularity 4)Location of the liver and stomach 5)Skin and subcutaneous tissue 6)Bones 7)Diaphragm and pleura
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INDIVIDUAL CHAMBER ENLARGEMENT
Left atrial enlargement Double-density on the right lower heart border Smooth left heart border Elevated left main-stem broncus
Left ventricular enlargement The apex of the heart is to the left and downward
Right atrial enlargement An increased prominence of the right lower
cardiac silhouette may be seen. Right ventricular enlargement
A lateral and upward displacement of the roentgenographic apex may be seen.
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INCREASED PULMONARY VASCULARITY
Enlarged right and left pulmonary arteries Vascular images extend into the lateral third
of the lung field. Increased vascularity to the lung apices.
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INCREASED PULMONARY VASCULARITY
Acyanotic child Atrial septal defect Ventricular septal defect Patent ductus arteriosus Atrioventricular septal defect Partial anomalous pulmonary venous return
Cyanotic child Transposition of the great arteries Total anomalous pulmonary venous return Hypoplastic left heart syndrome Truncus arteriosus Single ventricle
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NORMAL PULMONARY VASCULARITY
Obstructive lesions such as pulmonary or aortic stenosis
Small left-to right shunt lesions
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DECREASED PULMONARY VASCULARITY
Hilum appears small, the remaining lung fields appear black, and the vessels appear small and thin. Tetralogy of Fallot Pulmonary atresia Severe pulmonary stenosis Cyanotic heart diseases with pulmonary
stenosis
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PULMONARY VENOUS CONGESTION
The pulmonary veins are straight in their course and directed toward the central portion of the heart, the left atrium.
Pulmonary venous congestion is characterized by a hazy and indistinct margin of the pulmonary vasculature.
Kerley`s B lines Kerley`s A lines
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LOCATION OF THE LIVER AND THE STOMACH
Location of the liver and the stomach and the relation of these organs with the cardiac apex should be determined.
In abdominal situs solitus (normal) the liver shadow is on the right and the stomach gas bubble is on the left.
In abdominal situs inversus (mirror image) the liver shadow is on the left and the stomach gas bubble is on the right.
A midline liver is usually associated with complex congenital heart defects (heterotaxia syndromes).
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OTHERS
Skin and subcutaneous tissue Amphysema Calcifications
Bones Pectus excavatum Thoracic scoliosis Vertebral abnormalities Rib notching is a specific finding of coarctation of the
aorta in the older child (usually older than 5 years old) and usually found between the fourth and eight ribs.
Diaphragm and pleura The right diaphragm is higher one rib than the left
diaphragm.
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ELECTROCARDIOGRAPHY
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REFERENCES SYSTEMS İN ECG
Frontal reference system shows right-left, up-down DI, DII, DIII, aVR, aVL, aVF
Horizontal reference system shows right-left, front-back Precordial leads: V1,V2, V3,
V4, V5, V6
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Frontal reference system
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Horizontal reference system
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NORMAL PEDIATRIC ELECTROCARDIOGRAM
ECG of normal newborn shows 1)Right axis deviation 2)Dominant R waves in the right precordial
leads (V1) 3)Deep S waves in the left precordial leads
(V5-V6) 4)Positive T waves in the right precordial
leads
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TRANSITION TO ADULT ECG
Pediatric ECG features are age dependent. Right axis deviation decreases with age, Dominant R waves in the right precordial
leads decreases with age, T waves in the right precordial leads
should be upright in the first 2-3 days of life and inverted between 7 days of age and adolescence in normal children,
Heart rate decreases; PR, QRS, and QT interval increase with age.
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TRANSITION TO ADULT ECG(R and S waves)
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INTERPRETATION OF ECG
1)Heart rhythm 2)Heart rate 3)The QRS axis 4)PR, QT intervals and QRS duration 5)Atrial dilatation 6)Ventricular hypertrophy 7)ST segment and T wave
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RHYTHM
Sinus rhythm is the normal rhythm.
The P axis should be normal (0 to +90) in sinus rhythm. P wave must be positive in both D1
and avF or positive in one and on the isoelectrical line on the other
P waves should precede each QRS complex in sinus rhythm.
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Frontal reference system
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HEART RATE
The heart rate can be calculated by dividing 1500 in the number of small boxes between RR interval (during the ECG paper moves 25mm/sec). Heart rate=1500/RR small
boxes
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Frontal reference system
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QRS AXİS
Axis is calculated on frontal reference system (DI, DII, DIII, aVR, aVL, aVF)
DI and aVF (angle between them 90) are used
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QRS AXIS
Normal ranges of QRS axis vary with age.
Right axis deviation occurs when the axis is between the upper limit for age and 180
Left axis deviation occurs when the axis is between lower limit for age and -90
Northwest axis is between -90 and 180
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PR INTERVAL
Normal PR interval varies with age and heart rate.
Prolongation of PR interval (1 AV block) Atrial septal defect Atrioventricular septal defect Myocarditis Digitalis effect
A short PR interval Preexcitation syndromes (Wolff-Parkinson-
White syndrome) Glicogene storage diseases
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QRS DURATION
QRS duration increases with age 0,05- 0,10 second in children Increased QRS duration
Intraventricular block: methabolic or ischemic myocardial disease, hyperkalemia, some antiarrhythmic drugs (e.g., quinidine, procainamide)
Bundle branch block Preexitation syndromes Ventricular rhythm: premature ventricular
contractions, ventricular tavchycardia
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QT INTERVAL
The QT interval varies primarily with heart rate.
The heart rate corrected QT (QTc) Bazett’s formula QTc= QT/square root RR.
QTc interval should not exceed 0.44 sec, except in infants
A QTc interval up to 0.49 may be normal for the first 6 months of age
DII, V1 is the best leads to measure QT interval
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LONG QT INTERVAL
Long QT syndrome, Myocarditis, Diffuse myocardial disease, Head injury, Cerebrovasküler attack, Hipocalcemia, Drugs
Ampicilline, erythromycine, trimetoprim-sulpha etc antibiotics
Phenothiazines Tricyclic antidepressants Terfenadine
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ATRIAL DILATATION
Right atrial dilatation: Tall P waves>2.5 mm Left atrial dilatation:
1) Wide P waves > 0.10 sec (> 3 years old)
Wide P waves > 0.09 sec (< 3 years old) 2) P notching (it is seen in 10% of normal
children) 3) In lead V1, terminal negative portion of P
wave should be less than 0.04 sec and less than 1 mm deep (less than one small box by one small box) in normal children
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CRITERIAS FOR RIGHT VENTRICULAR HYPERTROPHY
1)Right QRS axis deviation 2)R wave greater than the upper limits of normal for the
patient`s age in V1, V2 3)S wave greater than the upper limits of normal for the
patient`s age in V6 4)R/S ratio in V1 and V2 greater than the upper limits of
normal for age 5)R/S ratio in V6 less than 1, after newborn period 6)A Q wave in V1 (pressure load: pulmonary stenosis etc) 7)rsR’ pattern in V1 (volume load: ASD etc) 7)Between 1 week and 6 years old, upright T wave in V1 In the presence of right ventricular hypertrophy, a wide
QRS-T angle (strain pattern)
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CRITERIAS FOR LEFT VENTRICULAR HYPERTROPHY
1)Left axis deviation (QRS axis) 2)R wave greater than the upper limits of normal
for the patient`s age in V5, V6, DI, DII,aVL and aVF 3)S wave greater than the upper limits of normal
for the patient`s age in VI and V2 4)R/S ratio in V6 greater than the upper limits of
normal for age 5)R/S ratio in V1 and V2 less than the lower limits
of normal for age 6)Q wave in V5 and V6, 5 mm or more 7)Tall symmetric T waves in V5 and V6 (volume
load: VSD, PDA etc 8)In the presence of left ventricular hypertrophy, a
wide QRS-T angle (strain pattern) (ST depression and inverted T waves in V5 and V6) (pressure load: AS etc)
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ST SEGMENT
The normal ST segment is isoelectric. Elevation or depression of the ST segment up to 1 mm in the limb leads and 2 mm in the precordial leads is considered normal.
Abnormal shift of ST segment Pericarditis Myocarditis Myocardial ischemia or infaction Digitalis effect
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T WAVES
T wave amplitude is variable in normal children
T waves in leads DI, DII and V6 should be more than 2 mm in all children over 48 hours old
An abnormally tall T wave is generally defined at any age as greater than 7 mm in a limb lead or 10 mm in a precordial lead
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T WAVES Tall peaked T waves
Left ventricular hypertrophy of the volume overload type Hyperkalemia Myocardial infaction Exercise Excitement Cerebrovascular attack
Flat, low or inverted T waves Hypoxia Ischemia Tachycardia Hipokalemia Hypotroidism Malnutrition Exercise Excitement Pericarditis Myocarditis Normal newborn
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