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CARDIOLOGIC DIAGNOSIS

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.

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CARDIOLOGIC DIAGNOSIS

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  1. CARDIOLOGIC DIAGNOSIS I.U. Cerrahpaşa Medical Faculty Department of Pediatrics Division of Pediatric Cardiology Prof. Dr. Ayşe Güler EROĞLU

  2. SUBJECTS • History • Physical examination • Inspection • Palpation • Oscultation • Innocent murmurs • Electrocardiogram • Telecardiogram

  3. HISTORY • Sweating • Exercise intolerance • Common respiratory tract infections • Growth retardation • Feeding difficulties • Palpitation • Dyspne • Cyanosis • Chest pain • Syncope

  4. 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)

  5. PHYSICAL EXAMINATION

  6. INSPECTION • General appearance • Chromosomal, hereditary, nonhereditary syndroms • Pallor • Cyanosis • Clubbing • Neck vein distension • Left precordial bulge

  7. 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

  8. VOLUME OF PULSES • Increase in pulse volume: pyrexia, fever, anemia, exerciseand 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

  9. 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.

  10. OSCULTATION • Heart rate and rhythm • Heart sounds • Other sounds • Murmurs

  11. 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).

  12. 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

  13. 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

  14. 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.

  15. OTHER SOUNDS • Ejection clic: It follows the S1very 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

  16. CHARACTERISTICS OF HEART MURMURS

  17. TIMING OF HEART MURMURS

  18. Sistolic ejektion murmurs(Diamond shaped, crescendo-decrescendo) Aortic stenosis Pulmonary stenosis Increased flow in aorta Increased flow in pulmonary artery

  19. Sistolic regurgitant murmurs(Holosistolic, pansistolic) Ventricular septal defect Mitral regurgitation Tricuspidregurgitation

  20. Early diastolic murmurs(Decrescendo) Aortic regurgitation Pulmonary regurgitation

  21. Middiastolic murmurs(Flow murmurs) Increased flow across the atrioventricular valves in patients with ASD, VSD, PDA

  22. Late diastolic murmurs(Presistolik) Mitral valve stenosis Tricuspid valve stenosis

  23. Continuous murmurs Arterial PDA Coronary artery fistula Pulmonary AV fistula Sistemic AV fistula Venous Venous ham

  24. 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

  25. LOCATION OF HEART MURMURS • Aortic area: right parasternal 2. intercostal space • Pulmonary area: leftparasternal 2. intercostal space • Tricuspid area:left parasternal 4.-5. intercostalspace • Mitral area(cardiac apex): 5.-6.intercostal space/ midclavicular line • Mezocardiyak area (second aortic area, Erb):left parasternal 3.-4. intercostal space Aorta Pulmonary Mitral Tricuspid

  26. 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.

  27. 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.

  28. TELECARDIOGRAM

  29. 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

  30. Thymus

  31. 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

  32. 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.

  33. 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.

  34. 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 • Hypoplasticleft heart syndrome • Truncus arteriosus • Single ventricle

  35. NORMAL PULMONARY VASCULARITY • Obstructive lesions such as pulmonary or aortic stenosis • Small left-to right shunt lesions

  36. 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

  37. 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

  38. 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. • Amidline liver is usually associated with complex congenital heart defects (heterotaxia syndromes).

  39. OTHERS • Skin and subcutaneous tissue • Amphysema • Calcifications • Bones • Pectus excavatum • Thoracic scoliosis • Vertebral abnormalities • Rib notching is a specific finding of coarctation of the aortain 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.

  40. ELECTROCARDIOGRAPHY

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