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Cardiac Examination.ppt

  1. Cardiac Examination
  2. LEARNING OUTCOME BY THE END OF THIS LECTURE STUDENTS SHOULD BE ABLE TO: Demonstrate knowledge to perform a cardiovascular examination in children.
  3. Introduce yourself to the patient +/- mother Ask permission and remove clothing from the upper part of the body. Place child at an angle of 45⁰
  4. General Inspection Observe child from the end of the bed ◦ Dysmorphic features ◦ Nutritional status ◦ Cyanosis ◦ Chest asymmetry ◦ Respiratory distress ◦ Plethoric facies ◦ Obvious scars
  5. Upper limbs - inspection Inspect hand for ◦ Clubbing ◦ Palmar pallor ◦ Splinter haemorrhages (under the nail bed; also check toe nails). ◦ Osler nodes( tender swollen 2-15mm)
  6. Upper limbs -palpation Feel for pulses ◦ Radial ◦ Brachial ◦ Feel both radial and femoral pulses ( absent femoral pulses with normal/increased brachial pulse suggests coarctation of aorta.
  7. Upper limbs - palpation  Assess the pulse for ◦ the presence ◦ Rate ◦ Rhythm ◦ Character or volume or amplitude ( e.g bounding, full, thready) • Lift up the arm to check for hyperdynamic pulsation (e.g aortic regurgitation)  Measure Blood pressure in both upper limbs
  8. Head and neck Inspection ◦ Look at conjunctivae for anaemia, jaundice (haemolysis due to artificial valves) ◦ Look in the mouth: ◦ Tongue – cyanosis ◦ Teeth for dental hygiene – Caries = risk for SBE ◦ Check JVP in order child (at 45⁰) Palpation ◦ With prior explanation ◦ Check if trachea is central ◦ Feel carotid thrill
  9. Chest -inspection  Note the Respiratory rate Scars Symmetry Apical pulsation
  10. Chest -palpation Feel the apex position ◦ Use sternal angle as guide (2nd ICS) ◦ Apex usually on 5th ICS in MCL
  11. Chest - Palpation cont’d Feel Thrill in all valvular areas ◦ Mitral –apex ◦ Aortic- 2nd ICS RSB ◦ Tricuspid- 4th ICS LSB ◦ Pulmonary-2nd ICS LSB heave ◦ Apex (LV), parasternal (left sternal edge -RV), substernal (RV). ◦ Pulmonary area for P2 (pulmonary hypertension)
  12. Chest - Auscultation With the stethoscope ◦ Listen in all the valvular areas ◦ Starting with the apex ◦ Feel pulse to time heart sounds and additional sounds
  13. Chest - Auscultation cont’d First heart sound (mitral and tricuspid closure) –best heard at apex/LLSB. Second heart sound (closure of aortic and pulmonary valves – ULSB (pulmonary area) Note for S1 and S2 intensities and whether S2 splits normally with respiration. Then, listen for any other sounds Roll to the left to accentuate mitral murmurs
  14. Chest - Auscultation cont’d Murmurs 1. Site 2. Radiation • Axilla (mitral) • Neck (aortic) • Back (pulmonary, coarctation)
  15. Chest - Auscultation cont’d 3. Timing ◦ Systolic - between S1 and S2 ◦ Ejection systolic murmur – interval between S1 and murmur. ◦ Regurgitant systolic murmurs – no gap between S1 and murmur. (MR, TR) ◦ Pansystolic ◦ Continuous ◦ Diastolic – between S2 and S1
  16. Chest - Auscultation cont’d 4. Intensity ◦ 1-6 for systolic ◦ 1-4 for diastolic 5. Character ◦ Eg , harsh(VSD), high pitched or blowing(MR,VSD), vibratory or humming (innocent )
  17. Chest - Auscultation cont’d Grading of Intensity ◦ Systolic ◦ Grade 1, barely audible ◦ Grade 2, soft but easily audible ◦ Grade 3, moderately loud but not accompanied by a thrill ◦ Grade 4, louder and associated with a thrill ◦ Grade 5, audible with the stethoscope barely on the chest ◦ Grade 6, audible with the stethoscope off the chest
  18. Chest - Auscultation cont’d Tilt patient forward ◦ Listen over the back for ◦ Radiation of murmurs ◦ Inspiratory crackles (especially the bases with left cardiac failure) ◦ Palpate back for sacral oedema (RVF)
  19. Systolic Murmurs at Various Locations LUSB ◦ Pulmonary valve stenosis ◦ Atrial septal defect ◦ Coarctation of the aorta ◦ PDA LLSB ◦ VSD ◦ Tricuspid regurgitation APEX ◦ Mitral regurgitation RUSB ◦ Aortic Valve stenosis
  20. ABDOMEN Palpate the abdomen for hepatomegaly ( congestive cardiac failure) Pulsatile liver (tricuspid incompetence) Splenomegaly ( SBE)
  21. Lower Limbs Inspection ◦ Clubbing ◦ Splinter haemorrhages Palpation ◦ Test for pitting oedema over the ankles ( (RVF)
  22. Eyes If SBE likely – Ophalmoscope for Roth spots.

Notas do Editor

  1. (Dysmorphic features: Down, Turner, Noonan, William, Marfan, Alagilles syndromes)
  2. Characteristics of an innocent murmur