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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 lowfrequency 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 Timing Radiation Location Murmur Intensity Quality TIMING OF HEART MURMURS Murmurs Systolic Ejection (Diamond Crescendodecrescendo) Regurgitant (Holosistolic Pansistolic) Continuous Early Late Diastolic 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 Pulmonary Aorta Tricuspid Mitral 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 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.