Cardiac examination.pptx.ppt in children

Cardiac exam

1. Level 4 Semester 8 Module (CWH II)

2. 2 Cardiovascular Examination

3. Name: Samah Elhindawy Department: Pediatrics Official e-mail: [email protected] Mobile or WhatsApp number (optional): Office hours: Day………. Available time: ……………day: 00:00-00:00 AM Office number and place: INSTRUCTOR INFORMATION 3

4. Mission and Vision of Faculty رسالة الكلية: تلتزم كلیة الطب البشري – جامعة الدلتا للعلوم والتكنولوجیا بتقدیم برنامج تعلیمي تكاملي متمیز یقوم على المھـارة والمعرفـة ویھـدف الى تخریج أطبـاء قـادرین على الوفـاء بواجبـاتھم المھنیـة والأخلاقیـة، والتعلیم الطبي المستمر والمشاركة الفعالة في البحث العلمي وخدمة المجتمع. رؤية الكلية: تسعى كلیة الطب البشري - جامعة الدلتا للعلوم والتكنولوجیا من خلال تطبیق برنامج التعلم القائم على اكتســاب الجدارات أن تكون في مقدمة المؤسسات الطبیة التعلیمیة المتمیزة على المستوى المحلي والقومى والعالمي .      

5. Inspection Palpation Percussion Auscultation Rt border Upper border Left border Lower 1/3 of sternum Bare area Prof. Samah Elhindawy Shape Skin Pulsations Apex beat” apical impulse” Other pulsations Heave Thrill Heart sounds Extra heart sound Additional sounds Murmur Pericardial rub

6. 6 Anatomy of the Heart Prof. Samah Elhindawy

7. Topographical Landmarks Precordium : the anterior chest surface overlying the heart. the precordium is divided into 4 areas : (1) Mitral (M) located at the cardiac apex in the 5 th ICS along the MCL. (2) Tricuspid (T) located in the Lt 4 th or 5 th ICS along the left sternal border (3) Aortic (A) located in the Rt 2 nd ICS along the right sternal border. (4) Pulmonary (P) located in the Lt 2 nd ICS near the left sternal border Prof. Samah Elhindawy

8. These optimal sites for auscultation do not correspond with the location of cardiac structures but are where the transmitted sounds and murmurs are best heard . Prof. Samah Elhindawy

9. (5) Erb's point located to the left of the sternum in the 3 rd ICS. - It is the approximate center of the heart. - At this point, you can listen for both the S1 and S2 Prof. Samah Elhindawy 5 areas of auscultation of the heart

10. In addition to these areas, auscultation of the precordium in between these areas is very important to avoid missing pathologic murmurs. For example; The murmur of a small, muscular VSD may be heard best in between pulmonary and tricuspid areas ?? In dextrocardia, heart sound and murmurs are better heard over the right precordium. What should you do before starting examination ??? Exposure of the patient’s chest from umbilicus upwards . The patient should be lying comfortable in the supine position with adjustment of the head of table to …………….degree angle ???? and shoulders horizontal. Prof. Samah Elhindawy

11. I. Shape of the precordium (Precordial bulge ?? ) Examine tangentially , first from the foot end of the bed & then from the patient’s right side directing a beam of light across the pericardium ???? If there is precordial bulge it denotes longstanding cardiomegaly. Inspection Shape Skin Pulsations ?? Chest deformities Remembering to check the axillae & posterior chest wall as well. Prof. Samah Elhindawy

12. II. Skin Pigmentations Scars Fistulae & sinuses Dilated veins 4. Midline sternotomy scar 1. Complex cardiac surgery 2. Coronary bypass surgery 3. PA banding 2. Right thoracotomy scar 1. BT shunt 2. PA banding Scars 1. Left thoracotomy scar 1. BT shunt 2. PA banding 3. PDA ligation 4. CoA repair 3. Left upper chest Pacemaker/ICD Prof. Samah Elhindawy

13. Dilated veins Veins on the chest wall, if prominent, must be noted & direction of flow is seen. In SVC obstruction , the blood flow in collaterals from above downwards . CoA The descending aorta and its branches are perfused by collateral channels from the axillary and internal thoracic arteries through the intercostal arteries. If child is asked to stand leaning forwards with arms hanging down by the sides , arterial collaterals may be visible and palpable on his back (intrascapular and infrascapular regions or posterior intracoastal spaces) in case of COA …. Suzman’s sign Prof. Samah Elhindawy

14. III. Pulsations Look tangentially , from the side of the patient for pulsations. ?? Pulsations : These are gentle flickers observed on the skin of the chest wall. A• Apical pulsation B• Epigastrium C. Aortic area D. Suprasternal area E• Pulmonary area F• Left parasternal area (3 rd & 4 th ICS) Prof. Samah Elhindawy

15. Palpation Apex beat +other pulsation Heaves Thrills . General rule: Fingertips : to feel pulsations Base of fingers : Thrills Base of hand ( or ulnar aspect ) : Heaves Prof. Samah Elhindawy

16. Prof. Samah Elhindawy

17. A. Palpation of apex 1. Site Localize the "apex beat“……. The apex beat may be visible on inspection. It is defined as the outermost and lowermost part of the heart at which the finger is lifted by the cardiac impulse , so called also “ apical impulse ”. It results from LV moving forwards and striking the chest wall during systole. Palpation of apical impulse is usually superior to percussion in detection of cardiomegaly. Its location and diffuseness should be noted ( A normal apical impulse briefly lifts your fingers and is localized ). Normally: > 7 years: 5 th Lt ICS at MCL Site Localized or diffuse 3. Character 4. Thrill Prof. Samah Elhindawy

18. Technique: Firstly , 1. If apical pulse can be detected by inspection , palpate by the right finger pads (palmer surface of fingers) to obtain a general impression of the cardiac impulse. 2. If apical impulse cannot be detected by inspection , the palm of the right hand placed in the region of the posterior axillary line. Then moved slowly in the medial direction in order not to miss an apex shifted outwards. 3. If you still not feel it , ask the patient to roll on to his left side (left lateral position). Prof. Samah Elhindawy 1. 2. 3. N.B Left lateral position NOT preferred to determine the character of the apex as it increases the apical pulsation and so misleading the original character.

19. Then , Locate the apex beat by laying your finger s on the chest parallel to the rib spaces. Its exact site & character should be determined with the tip of the index finger . Finally , Count the intercostal spaces (first identify the angle of Louis= the rib attached alongside this is the 2 nd rib and the space below the rib is the 2 nd space). Percussion or auscultation may be used for detection of absent apex . Apex beat in 5 th ICS in MCL Prof. Samah Elhindawy

20. Causes of absent apex: Shifting of apex: - Conditions outside the heart: a) Displaced to left: Cardiomegaly , pectus excavatum, scoliosis. b) Displaced to right: Congenital dextrocardia (feel for liver- Kartagener syndrome), Left diaphragmatic hernia. c) Fibrosis & collapse: pull the heart towards the lesion. d) Pleural effusion & Pneumothorax: push the heart away from the lesion. d) Ascites, large tumor, gas distension: displace the apex upwards & to the left. - Causes in the heart: a) LV enlargement: apex is shifted down and outward b) RV enlargement: apex is shifted outward Prof. Samah Elhindawy

21. 2. Localized or diffuse - Normally, the pulsation at the apex don not exceed 2 finger breadth . - If the pulsation extend over 2 ICS , it is called a diffuse apex and denotes RVH . 3. Character of apex (force & duration) Normal apex ( gentle non-sustained tap formed by LV) Slapping apex ( palpable 1 st heart sound ) - present in MS due to loud S1 Heaving apex ( forcible & sustained ): - Its duration is much longer - It is felt as lifting of the palpating hand of prolonged duration - It is usually present in ventricular hypertrophy ( pressure overload ) as in systemic hypertension, AS, CoA Hyperdynamic apex ( forcible & non-sustained ): in ventricular dilatation ( volume overload ) as AR, MR, VSD 4. Thrill 90% of thrill of apex are diastolic due to MS. ?? Systolic Prof. Samah Elhindawy

22. C• Aortic area pulsation (2nd Rt ICS) Other pulsations B• Epigastric pulsations 1) RVH (If you put your thumb in the epigastrium, pulsation from above ) 2) Aortic in origin usually in thin persons, OR in aortic aneurysm (pulsation from below ) 3) Expansile pulsation of the liver present in TR and associated with hepatomegaly (pulsation from Right ) hepatic pulsation is felt by one hand anteriorly placed over the liver and the other hand placed posteriorly. denotes any cause producing aortic dilatation e.g. aortic aneurysm, or hypertension Prof. Samah Elhindawy

23. E• Pulmonary area pulsation (2 nd Lt ICS) - A sound may be felt in this space ( diastolic shock ) i.e. palpable accentuated P2 indicating pulmonary hypertension . D• Suprasternal pulsations In a semi setting patient, Place your index in supra sternal notch. 1) AR 2) High aortic arch 3) Aneurysm for aortic arch 4) Hyperdynamic circulatory states e.g. anemia, thyrotoxicosis, etc Prof. Samah Elhindawy

24. - Left parasternal Pulsations may be just a pulsations Or heave . ( Heave : pulsation which lift your hand upward) - Parasternal heave is a precordial impulse that can be palpated. - Place the heel of your hand parallel to the left sternal edge ( fingers vertical ) to palpate for heaves. - If heaves are present you should feel the heel of your hand being lifted with each systole. - Parasternal heaves are typically associated with RVH . ?? Apical Heave ?? Parasternal Heave F• Palpation in Lt parasternal line (3 rd & 4 th ICS) ( Pulsation & Heave ) Prof. Samah Elhindawy

25. A thrill is a palpable vibration caused by turbulent blood flow (thrill is a palpable murmur; palpable manifestations of loud murmur). Assess for a thrill across each of the heart valves in turn. Place your hand horizontally across the chest wall, with the roots of your fingers over the valve to be assessed. However, the fingers are used to feel a thrill in the suprasternal notch and over the carotid arteries. Thrill Prof. Samah Elhindawy Causes of Thrill

26. Lower border of the heart cannot be percussed as being continuous with liver dullness . Rt border Upper border Lt border Lower 1/3 of sternum Bare area Percussion Prof. Samah Elhindawy

27. Percussion of Rt border This is determined by firstly percussing for the upper border of liver by heavy percussion (normally found in right 5 th ICS). The ICS above the hepatic dullness is next percussed from Rt to Lt with the hand parallel to the Rt sternal border . The Rt border of the heart is behind the sternum & so no dullness can be elicited normally to the Rt of sternum . Causes of dullness to the Rt border of sternum : 1. RA enlargement 2. Aneurysm of ascending aorta 3. Pericardial effusion 4. Dextrocardia 5 . Chest causes Prof. Samah Elhindawy

28. Percussion of upper border Percuss the 2 nd Rt & 2 nd Lt ICS in parasternal line ( light percussion) starting from outward medially with the hand parallel to the sternal border . Normally the upper border of the heart is at the level of the 3 rd cartilage thus the 2 nd Lt & 2 nd Rt ICS are normally resonant . Dullness in the 2 nd spaces on both sides may be due to pericardial effusion . Dullness in the 2 nd Rt space is due to aortic aneurysm . Dullness in the 2 nd Lt space is due to pulmonary hypertension or pulmonary artery dilatation . Prof. Samah Elhindawy

29. Percussion of left border (Apex)+ (Waist= 3 rd Lt ICS ) Percuss from the axilla inwards ( heavy percussion) 1. 1 st in the space of the apex (5 th ICS) & 2. Next the 4 th & 3 rd spaces. Normally no dullness outside the apex, ??? waist Dullness outside the apex: pericardial effusion or chest causes. Obliteration of the waist (increased dullness): LA enlargement or chest causes. Prof. Samah Elhindawy 1. 2. Percussion over lower 1/3 of the sternum Light percussion either direct or indirect . Normally, it is resonant . If dull indicates RV enlargement or pericardial effusion .

30. Prof. Samah Elhindawy Percussion of the bare area of the heart Bare area is the area of the heart not covered by lung tissue= cardiac notch in the Lt 4 th & 5 th spaces between midline and parasternal line ) Percuss from the axilla inwards in 4 th & 5 th ICS ( heavy percussion) to detect Lt border of the heart. Then by light percussion to detect the bare area: 1- Classic way: from outside inward (Lt 4 th & 5 th ICS) 2- Alternative way: from above downward (Lt 3 rd , 4 th & 5 th ICS) Normally, it is dull “ impaired note” and does not extend beyond parasternal line . Wide bare area of the heart present in: 1) RV enlargement 2) Pericardial effusion 3) Chest causes Resonant in: emphysema , left pneumothorax , or dextrocardia 1. 2.

31. Heart sounds Extra heart sounds Additional sounds Murmurs Pericardial rub Auscultation Bell vs diaphragm of the stethoscope Use the diaphragm to identify S1 & S2 , and high-frequency sounds such as ejection systolic murmur of AS , early diastolic murmur of AR and pansystolic murmur of MR . Listen with the diaphragm over the whole precordium for a pericardial friction rub . The bell is more effective at detecting low-frequency sounds. The bell is particularly useful at the apex and left lower sternal border to listen for the diastolic murmur of MS and, S3 & S4 . The diaphragm attenuates all frequencies equally, thus making some low-frequency sounds less audible. Prof. Samah Elhindawy

32. Areas of auscultation Prof. Samah Elhindawy ????

33. I. Heart sounds S1 & S2 The first heart sound ( S1 ), ‘ lub ’: It is produced by almost simultaneous ?? closure of mitral & tricuspid valve at the onset of ventricular systole. The aortic & pulmonary valves then open inaudibly . It is heard over M & T areas. The second heart sound ( S2 ), ‘ dub ’: It is caused by closure of the aortic and pulmonary valves at the end of ventricular systole. After a brief period, mitral & tricuspid valve open inaudibly . It is heard over A & P areas . Intensity Splitting Prof. Samah Elhindawy

34. S2 has 2 component (Aortic: A2 & Pulmonary: P2 ) because of the lower pressure in RV compared with LV, pulmonary valve closes later than aortic valve ( physiological splitting ). Normally, S2 is louder and higher-pitched than S1 and, A2 is louder than P2 . This splitting increases at end-inspiration because increased venous filling of RV further delays pulmonary valve closure. The separation disappears on expiration . On auscultation, ‘ lub d-dub ’ (inspiration) ‘ lub -dub ’ (expiration) is heard. ( Split S2 ) Because of A2 component is louder, it is radiates widely over the precordium. While P2 is heard mainly on pulmonary area with some radiation down the left sternal border. Therefore, P2 component and A2 component heard over the pulmonary area and so the physiological splitting . Prof. Samah Elhindawy

35. Change of intensity of heart sounds Accentuated S1& S2 Thin person , Children. & hyperdynamic state. Muffled S1& S2 Mechanical factor e.g. thick chest wall, obesity, emphysema, pericardial effusion (distant heart sound). Shock - hypotension S1 Accentuated in MS (due to elevated LA pressure). Muffled in MR , TR S2 Accentuated in pulmonary hypertension (P2) systemic hypertension (A2) Muffled in PS , AS (Low pressure gradient of closure). Prof. Samah Elhindawy

36. Physiological and pathological splitting of S2 Fixed splitting S2 ( ASD ) During Expiration , blood passes from L.A to R.A ➔ ↑ Load on Rt & ↓ Load on Lt ➔ (Aorta valve closes before Pulmonary). During inspiration ➔ ↑ Venous return to R.A which equalize pressure of L.A ➔ Stoppage of shunt, so return to normal physiology (Aorta valve closes before Pulmonary). Cardiac ex findings in ASD ?? Prof. Samah Elhindawy

37. II. Extra Heart sounds (S3 & S4) The third heart sound ( S3 ): S3 is a low-pitched early diastolic sound best heard with the bell at the apex . To best hear S3, patient should be in the left lateral decubitus position. It coincides with rapid ventricular filling immediately after opening of the atrioventricular valves and is therefore heard after S2 as ‘ lub -dub- dum ’ …. Protodiastolic Distinguishing S3 from split S2 : 1- Split S2 is high -pitched while S3 is a low -pitched sound (heard using the bell should disappear when the diaphragm is used ) 2 - Split S2 is best heard at pulmonic while S3 sound is heard best at apex . It may be a normal physiological finding in children , young adults and febrile patients . It can be an important sign of systolic heart failure ; In this setting, the myocardium is usually overly compliant, resulting in a dilated LV and during passive filling, blood strikes it producing S3. Prof. Samah Elhindawy

38. The fourth heart sound ( S4 ): S4 is less common. It is soft and low-pitched , best heard with the bell at the apex . It is always pathological and is caused by forceful atrial contraction against a non-compliant or stiff ventricle . It occurs just before S1 ( da- lub -dub ).... Presystolic An S4 is most often heard with LV hypertrophy (due to hypertension, or aortic stenosis). Gallop : additional or extra heart sounds (3rd or 4th) plus tachycardia . It is so called because it is a triple rhythm resembles the sound of a galloping horse. S3 gallop = protodiastolic gallop S4 gallop = presystolic gallop Summation Gallop : Third & fourth sounds plus tachycardia Prof. Samah Elhindawy

39. III. Additional sounds (Snap & Click) Opening snap : - An opening snap is commonly heard in MS (rarely, TS ). It results from sudden opening of a stenosed valve . - It occurs early in diastole , just after S2 . It is best heard with the diaphragm at the apex . Ejection click : - Ejection click is heard with congenital PS or AS. mechanism is similar to that of an opening snap. - It occur early in systole just after S1. It is high-pitched sounds best heard with the diaphragm . Mid-systolic click : - Mid-systolic click is heard in mitral valve prolapse . It may be associated with a late systolic murmur. - It is high-pitched and best heard with the diaphragm at apex . Prof. Samah Elhindawy

40. IV. Murmurs Heart murmurs are produced by turbulent blood flow. Mechanism of Turbulence (murmur): • Passage of blood through Stenosis (AS/ MS/ PS) • Shunt (VSD/ PDA) • Abnormal direction of Blood (MR/AR) • Over blood flow ( relative stenosis ) • Passage of blood into a relatively dilated structure (ejection systolic murmur in PH or systemic hypertension) Prof. Samah Elhindawy

41. Comment on : ( 6 : Script ) S ite (6 × 6) C haracter R elation (increased by) I ntensity (grading) 6 P ropagation T iming T iming : - Identify S1 and S2, respectively. It may help to palpate the patient’s carotid pulse while listening to the precordium to determine the onset of ventricular systole . Determine whether the murmur is systolic or diastolic. - AS/ MR / TR/ VSD = systolic. AR/ MS = Diastolic. Prof. Samah Elhindawy

42. The murmur of AS or PS begins after S1 reaches maximal intensity in mid-systole, then fades, stopping before S2, producing ejection systolic murmur . (PS) Systolic murmurs The murmurs of MR and TR start with S1, sometimes muffling or obscuring it, and continue throughout systole ( pansystolic ). Also, The murmur of VSD is pansystolic. The murmur produced by mitral valve prolapse does not begin until the mitral valve leaflet has prolapsed during systole, producing a late systolic murmur. Prof. Samah Elhindawy

43. Prof. Samah Elhindawy Diastolic murmurs Murmurs of AR and PR are early diastolic murmurs . - The murmurs produced by MS or TS ( anatomic or relative ) are low pitched and best heard with the bell applied lightly on the chest. They are Mid-diastolic murmur begins after the opening snap . ( diastolic rumbling murmur of MS ) Continuous murmurs Murmur of PDA is louder in systole (crescendo) peaking at S2, and diminishing in diastole (decrescendo) maximally heard in Lt infraclavicular area or along the upper left sternal border ( machinery murmur of PDA )

44. C haracter : • AS= Harsh. • AR= Soft blowing. • MS = Rumbling. • MR = Soft (80%), harsh = (20%) Prof. Samah Elhindawy I ntensity (Grades):

45. R elation (to respiration & position) increased by ……. - Mitral murmur : By • Left lateral position. • Exercise. Aortic murmur : By • Leaning forward. • Expiration. Right sided murmurs: By Inspiration " Carvallo's sign " Prof. Samah Elhindawy

46. Prof. Samah Elhindawy S ite : His helps to differentiate diastolic murmurs ( MS at the apex, AR at the left sternal edge) . but is less helpful with systolic murmurs, which are often audible across the precordium. P ropagation (Radiation): Murmurs radiate in the direction of the blood flow to specific sites outside the precordium . P ansystolic murmur of MR radiates towards the left axilla. Murmur of VSD towards the right sternal edge. Murmur of AS to suprasternal notch and carotid arteries .

47. V. Pericardial rub Pericardial rub (friction rub) is coarse scratching, high pitched sound caused by friction of parietal & visceral layer of pericardium. It is best heard at the left of the lower sternum with the patient breathing out using the diaphragm of the stethoscope. Timing: To & Fro = Systolic & Diastolic. D.D.: Pleural rub:- disappeared by withholding breath Friction of stethoscope: disappeared by firm pressure Prof. Samah Elhindawy

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