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    Cvs Examination New

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    Shreya Praveen

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    Cvs Examination New

    Uploaded by

    Shreya Praveen
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    Copyright:

    © All Rights Reserved
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    Download as pptx, pdf, or txt
    3 views38 pages

    Cvs Examination New

    Uploaded by

    Shreya Praveen

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 38

    Examination of

    CVS

    Dr Anjima Soman
    Junior Resident.
    History –In neonates
    and infants
    • Interrupted feeding
    • Fast breathing
    • Excessive forehead sweating
    • Recurrent LRTI
    • Cyanosis
    • Failure to thrive
    • Swelling of eyelids and feet (rare)
    HISTORY-In older children

     Dyspnea

     Chest pain - pericarditis, MVP, AS, Hypertrophic


    cardiomyopathy

     Orthopnea

     PND
     Cyanosis – of CHD appears at birth or within 3-5
    days when ductus closes.
    Ask whether cyanosis improve or worsen with
    crying

     Palpitations-Heart blocks, arrhythmias, volume


    overload states

     Syncope – Severe AS, CoA, Heart blocks,


    tachyarrhythmia
    Cyanotic HD may be assoc with syncope
     Edema – pedal edema in RHF

     Squatting – cyanotic HD,eg.TOF


    • Ask for symptoms of CCF like
    o Poor feeding (suck rest cycle)
    o Breathes better when held against sholuder ( equivalent to
    orthopnea)
    o Excessive head sweating ( due to increased sympathetic
    activity and large surface area of head)
    o Poor weight gain
    o Persistent wheeze and coughing
    • Always ask history to differentiate respiratory
    cause of breathlessness from cardiac causes like
    fever, cough, sputum production
    • Paroxysmal hypercyanotic spells(blue or hypoxic
    or tet spells)- in 1st 2 years in children with
    CCHD.Spells occurs due to acute decrease in
    pulmonary blood flow; increased R to L shunt and
    systemic desaturation .When severe, it is
    associated with severe hypoxia and metabolic
    acidosis.
    • Squatting-
    • Increases PVR
    • Decreases R to L shunt
    • Increases intrathoracic pressure
    • Symptoms of bacterial endocarditis –fever,skin
    rash,sudden onset pallor,reddish spots on nail
    beds

    • Symptoms of CNS complications like intracranial


    abscess/CVA – fever, vomiting, seizure, FND,limb
    weakness, paralysis
    Other points in history

    Perinatal history

    IU infection – fever with rash, Rubella – PDA , PS


    DM- Asymmetric septal hypertrophy, VSD, TGA
    Drugs - Li: Ebstiens , Phenytoin or valproate :
    septal defect

    Prematurity – PDA

    Growth and development


    Gen. examination
    • Look for the general condition of the child

    • Pallor – anemia can precipitate cardiac failure


    • Cyanosis
    • Clubbing - CCHD
    • Icterus – Liver congestion due to RHF
    • Pedal edema – RHF
    • JVP
    Other gen examination findings
    • IE- splinter h’ges, osler nodes, janeway lesions

    • RF : Subcutaneous nodules, joint swelling, chorea, rash etc

    • Marfanoid habitus : MR

    • Cataract : CRS

    • Webbing of neck : Turner and noonan (bicuspid aortic valve,


    CoA, PS)

    • Elfin facies : Supravalvular AS

    • Distal radial anomalies : Holt Oram syndrome (secundum


    ASD)
    • Cleft palate: 20% chance of heart disease
    Vitals
    • PULSE
    o RATE
    • Tachycardia ; SVT, AT, AF, VT, Sinus tachycardia
    • Bradycardia : AV block, sick sinus syndrome, long QT syndrome,
    Complete bundle branch block
    o RHYTHM
    • Regularly irregular : Ectopics
    • Irregularly irregular : AF
    o VOL and CHARACTER
    • High vol : AR, PDA
    • Low vol : AS, CoA
    • Water hammer : AR, PDA
    • Pulsus alternans: LVF
    • Pulsus paradoxus: Cardiac tamponade
    o RF delay
    • Femoral pulse slightly delayed in CoA
    • Resp rate
    o Tachypnea in CHF, anoxic spells, pulm. emboli

    • Blood pressure

    o Cuff size
    • Length of inflatable bladder must cover at least 80% of the
    arm circumference
    • Width of the bladder should cover at least 2/3 rd of the
    length of arm from acromion to olecranon process
    • Korotkoff’s sounds
    1. Sounds begin to appear. This is the systolic BP

    2. Louder sounds, sometimes with a murmur like tail

    3. Higher intensity tapping sounds

    4. Muffling

    5. Total disappearance of sounds.

    Earlier phase 4 used to be taken as diastolic BP, now phase 5


    is taken at all ages. However in situations like AR, phase 4 is
    taken
    o Measure BP from both arms – Difference >10mmHg in CoA
    o Also in Supravalvular AS
    o Look lower limb BP – usually 10-30 mmHg more than upper
    limb
    o In CoA, lower limb BP is lower while in AR, LL BP is atleast
    40mmHg higher than UL (hill’s sign)

    • Temp
    o Rheumatic HD, SABE, Pulm infarction
    EXAMINATION-Precordium
    • INSPECTION
    o Shape of the precordium
    • Bulging precordium in long standing cardiomegaly
    • Bulging intercostal spaces- pericardial effusion
    • Pectus excavatum / carinatum

    o Visible pulsations
    • Suprasternal – hyperdynamic states, AR, CoA
    • Epigastric pulsation- RVH
    • Hepatic pulsation- TR/TS

    o Dilated veins over chest- SVC obstruction


    o Surgical scars – open heart surgery, shunt surgeries,
    PDA ligation or coarctation repair

    o Identify the site of apex beat if possible

    o Look for jugular venous pulsations


    PALPATION
    • Apex
    Whole palm placed over precordium, and then the exact point of apex beat is
    located using a single finger.
    Note the space at which apex is located and its position in relation to MCL.

    Position of apex
    < 4yr 4th ICS 1cm lat to MCL
    4-7 yr 5th ICS On MCL
    >7yr 5th ICS 1cm medial to MCL

    Character

    Tapping apex – palpable S1 (MS)


    Heaving (forceful,broad and sustained) - LVH
    Hyperkinetic/ forceful apex - vol overload states (anemia , AR, PDA, VSD,
    MR, Thyrotoxicosis)
    • Left parasternal heave

    Place the ulnar border of hand over the sternum at 4-5th ribs,
    and watch extended fingers of the hand for subtle movements.

    A definite parasternal lift along with epigastric pulsation is


    invariably due to RVH

    • Epigatric pulsation

    o Palpate with thumb just below xiphisternum


    o If pulsations are felt on finger tips – RVH
    o Palmar side of finger – aortic
    o Pulsation felt on right side of thumb - hepatic
    • Thrills

    o Palpable vibration of murmur.


    o Assoc with a murmur of grade 4 or more.
    o Presence of thrill is more certain evidence of underlying
    organic disease
    o Functional murmurs are never assoc with a thrill

    o Thrill of AS is best felt in sitting up leaning forward position


    o That of MS best appreciated in left lateral position.
    o VSD, MR and PDA are other lesions assoc with murmur.
    • Palpation of the base of heart

    o Child sitting and leaning forward


    o Place ulnar aspect of hand transversely covering both
    aortic and pulmonary area.
    o Pulsation in aortic area may be due to thrill of AS
    o Abnormal pulsation in pulm area seen in PAH, Enlarged
    PA (idiopathic pulm artery dilatation or PS with post
    stenotic dilatation) or in increased pulm blood flow as in
    ASD or VSD
    PERCUSSIO
    N

    • Locate the upper border of liver dullness by percussion

    • Cardiac borders are located with light percussion, first left


    border followed by right border.

    • Pleximeter finger should be parallel to the expected cardiac


    border

    • Percuss the pulm area – area of dullness in normal adult is


    2.5cm from the midline or less, no pediatric standards.
    AUSCULATATION

    • Usual areas auscultated

    o Mitral area, Tricuspid area, Pulm area, Aortic area


    o 4th and 5th space close to the sternum – VSD murmurs are
    loudest here.
    o Below the clavicle – murmur of PDA, Venous hum
    o Carotids – mainly for bruit as in AS
    o Inter and infra scapular areas for murmurs of coarctation and
    collateral murmurs
    o Axilla – may be auscultated esp in MR to look for conduction
    of murmur.
    First heart

    sound

    • Loud S1
    o Tachycardia
    o Increased AV flow – ASD, PDA
    o Short PR interval
    o Prolonged AV flow due to stenosis – MS and TS

    • Soft S1
    o Poor conductance – obesity, emphysema, pleural or pericardial
    effusion
    o Prolonged PR interval – 1st degree heart block
    o Severe calcification or reduced mobility of valve
    • Variable intensity of S1
    o AV dissociation – CHB
    o AF
    2nd heart
    sound
    • Composed of A2 And P2

    • Normal split of s2
    o With inspiration, A2-P2 widens and are heard seperately, whereas in
    expiration it narrowsand only single sound heard

    • Wide split
    o Delayed P2 – RBBB, PS, PAH,
    o Early A2 – MR and VSD

    • Single S2
    o P2- in severe PAH, loud P2 masks A2
    in severe AS where A2 is soft
    o A2 - In TOF where loud A2 masks soft P2
    • Reverse split – either delayed A2 or early P2
    o Delayed A2 – LBBB , prolonged LV ejection time (AS)
    o Early P2 – early activation of RV (WPW)
    • Additional sounds like S3, S4, opening snap,
    clicks, pericardial rub etc

    • S3 – ventricular distension sound, best heard at apex


    • S4 – atrial contraction sound

    • Clicks – normal valve openings are silent,


    abnormal valves open with a click.
    o Click in early systole seen in valvular AS/PS
    o Ejection click of PS best heard in expiration.
    o Mid systolic click - MVP
    • Opening snap
    o High pitched sharp sound in diastole , immediately after S2
    o Best heard inside the apex rather than at the apex

    o Seen in MS
    o In combines MS-MR lesion, if MR predominant, opening snap is not
    heard.
    o Does not dissappear even if AF is present
    Murmurs
    • Murmurs to be described under the following:-

    • Site
    • Timing
    • Intensity
    • Pitch
    • Character or quality
    • Conduction or transmission
    • Systolic murmurs:- Ejection systolic, Pansystolic
    murmurs
    • Diastolic murmurs- early, mid, late Diastolic
    murmurs
    •
    Thank you

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