cardiovascular examination i.u. cerrahpaşa medical faculty department of pediatrics division of...
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CARDIOVASCULAR EXAMINATION
I.U. Cerrahpaşa Medical Faculty
Department of Pediatrics
Division of Pediatric Cardiology
Prof. Dr. Ayşe Güler EROĞLU
HISTORY
Sweating Exercise intolerance Common respiratory tract infections Growth retardation Feeding difficulties Palpitation Dyspne Cyanosis Chest pain Syncope
HISTORY
Medical history Ilnesses Medications
Prenatal history Mother’s ilnesses (diabetes mellitus, lupus) Mother’s medications
Natal history Prematurity Birth weight
Family history Congenital heart diseases Sudden death
PHYSICAL EXAMINATION
INSPECTION
General appearance Chromosomal, hereditary, nonhereditary
syndroms Pallor Cyanosis Clubbing Neck vein distension Left precordial bulge
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
VOLUME OF PULSES
Increase in pulse volume 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
OSCULTATION
Heart rate and rhythm Heart sounds Other sounds Murmurs
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: Fever, 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).
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
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
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.
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
CHARACTERISTICS OF HEART MURMURS
Location
Intensity Quality
Radiation
Timing
Murmur
TIMING OF HEART MURMURS
Murmurs
Systolic Continuous Diastolic
Ejection(Diamond Crescendo-
decrescendo)
EarlyRegurgitant(HolosistolicPansistolic)
Late Early Middiastolic Late
Sistolic ejektion murmurs(Diamond shaped,
crescendo-decrescendo)
Aortic stenosis Pulmonary stenosis Increased flow in aorta Increased flow in pulmonary artery
Sistolic regurgitant murmurs(Holosistolic, pansistolic)
Ventricular septal defect Mitral regurgitation Tricuspid regurgitation
Late sistolic murmurs
Mitral valve prolapse Tricuspid valve prolapse
Early diastolic murmurs(Decrescendo)
Aortic regurgitation Pulmonary regurgitation
Middiastolic murmurs(Flow murmurs)
Increased flow across the atrioventricular valves in patients with ASD, VSD, PDA
Late diastolic murmurs(Presistolik)
Mitral valve stenosis Tricuspid valve stenosis
Continuous murmurs
Arterial PDA Coronary artery
fistula Pulmonary AV fistula Sistemic AV fistula
Venous Venous hum
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
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.