Approach to the Diagnosis of Heart Diseases 2

7/21/2019 Approach to the Diagnosis of Heart Diseases 2

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PPRO CH TO THE

DI GNOSIS OF HE RTDISE SES IN CHILDREN

History and Physical Examination

Edgardo E. Ortiz, MD, MHSA, FPPS, FPCC, FAsPCCProfessor and Chair

Department of Pediatrics

College of Medicine-Philippine General Hospital

University of the Philippines Manila



Approach to Heart Diseases

in Children

Congenital vs. Acquired?

– History – Physical Examination

– Chest X-Ray

– EKG – 2DEchocardiography



History

Maternal & Birth

Family

Past



Maternal History

Infections

Medications

Alcohol intake



Maternal History

Infections: 1st trimester of pregnancy

1. German measles - Congenital RubellaSyndrome; PS; PDA

2. Cytomegalo virus - teratogenic

Herpes myocarditis – last trimester

Coxsackie B



Maternal History

Illness

1. DM - cardiomyopathy (ASH)

- structural (VSD, TGA,PDA)

2. SLE - Heart Blocks

3. CHD - 15% incidence of CHD

( vs 1% general pop.)



Maternal History

Medications

1. Amphetamines (uppers) – VSD, PDA, ASD, TGA

2. Anticonvulsants

a) Diphenylhydantoins – PS, AS, COAb) Trimethadione – TGA, TOF, HLHS

3. Progesterone/Estrogen – VSD, TGA, TOF

Alcohol - Fetal Alcohol Syndrome- VSD, PDA, ASD, TOF



Past History

1. Cyanosis including “spells”

2. CHF

3. Weight gain/feeding

4. Heart murmur

5. Frequent Respiratory Infections(lower)



Cyanosis - deep & fast breathing

vs

Breath holding spell - holding breath

Cyanosis – birth (or 2 wks of life)emergency



CHF

Onset

L R

TGA etc



CHD

Weight affected more than the height

Weight severely affected – dysmorphicconditions



Past History

Others:

Chest pains

Joint swellings

Neurologic symptoms



Family History

Hereditary Disease

Congenital Heart Disease

___________RF

Hypertension/Atherosclerosis



Family History

Hereditary

Holt Oram AD ASDMarfans AD AR/IMR

Williams AD supra valvar AS/ PA steins



Family History

CHD

Incidence in general population – 8 to

12/1000 live births Recurrence Risk related to recurrence

risk of the syndrome or H.D.

One child affected – risk recurrence insibling – 3% (VSD)

– 2.5 % (TOF)



Family History

Defect Mother Affected

(%)

Father Affected

(%)

Aortic stenosis 13.0 -18.0 3.0

Atrial septal defect 4.0 – 4.5 1.5

Patent ductus arteriosus 3.5 – 4.0 2.5

Tetralogy of Fallot 6.0 – 10.0 1.5

Ventricular septal defect 6.0 2.0



Approach to Heart Diseases in

Children

• Congenital vs. Acquired:

– HISTORY

• Maternal and family history

• Age of onset of symptoms

– <2 yrs – congenital

– 2-5 yrs – congenital/acquired

– >5 yrs - acquiredExceptions:

» CHD w/ late onset manifestations

» Acquired heart diseases in the young




NormalHeart




C



Congenital Heart DiseaseNormal Cardiac Chamber

Oxygen Saturations



Inspection and Observation

• General appearance – Comfortable , playful

– Breathing pattern

– Cardio-pulmonary distress

• Color – Pink, pale or cyanotic

• Nutritional status – Normal

– Malnourished – undernourished or obesity

• Genetic abnormalities



Cyanosis

• 5 gm% of desaturated Hb

• Bluish discoloration ofnailbeds, skin, oral mucosa

• Difficult to detect if 02

sat >85% or anemia

• Central vs. peripheralcyanosis – hyperoxic test

• Needs immediateintervention in neonates



Inspection and Observation

• Nutritional status – Normal

– Malnourished – undernourished orobese

http://www.rush.edu/worldbook/articles/900090b/900090652.html

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Inspection & Observation :

Genetic Abnormalities

Trisomy 21 Trisomy 13 Trisomy 18



Inspection: Head

• Head bobbing – Severe AR

• Eyes

– Cataract, congestedconjunctivae,hypertelorism

• Face – edema

• Mouth – Color of lips & tongue;

teeth, tonsils

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Inspection & Palpation : Neck

• Back of the neck

– Acanthosis nigricans ; looseness;webbing

• Pulsations

– Arterial : carotid – aortic run-off lesions

• Corrigan’s pulses

– Venous : jugular

• Normal

• Distended : severe TR



Engorged Jugular Vein



Inspection & Palpation : Chest

• Normal

– Adynamic precordium

– Apex beat

– Point of maximal impulse

• Abnormal

– Retractions

– Dynamic, hyperactive

– Precordial bulge

– Pectus excavatum &carinatum

– Harrison’s groove




Sternal retraction

- poor lung compliance




Subcostal retraction – airway obstruction or

pulmonary congestion



Chest Deformity

Pectus CarinatumPectus Excavatum



Inspection & Palpation: Chest

• 1/M with moderate size

VSD became smaller

• Dynamic precordium

• Precordial bulge

• Harrison’s groove

• Thrill




• Apex beat – most

lateral cardiac

impulse

• Point of maximalimpulse






Palpation: Chest

• Heave

– Impulse with double contour : volume

overload

• Tap

– Well localized sharp rising impulse : pressure

overload



Apex Beat



Palpation : Chest

RV Heave Subxiphoid impulse



Palpation : Chest

• Thrill

– Vibration detected distal to jet lesions from

cardiac defects ; loud murmur

– LUSB : Pulmonary stenosis, PDA , VSD ,AS

– LMSB : PS, VSD

– LLSB : VSD, TR

– Apex : MS, MR



Inspection & Palpation:

Abdomen• Distension – ascites

• Pulsatile abdominal aorta – aortic run-off

• Liver – Infants : soft palpable 2 –3 cm BRCM

1 year old : 2 cm & 4 – 5 years old : 1 cm

– Hepatomegaly : hallmark of systemic venous

congestion in infants – Pulsatile liver : TR or inc. RA pressure



Inspection & Palpation :

Extremities

• Marfan’s syndrome

Thumb Sign Wrist Sign

Arachnodactyly




Extremities

• Edema : not common in infants with heartdisease; usually due to presence of TR




Extremities

Hands & feetCyanosis : clubbing of fingers & toes




Extremities

Hands & feet :Differential cyanosis

• Hands pink & feet cyanotic – PDA with severepulmonary HTN

• Hand cyanotic & feet pink – TGA withcoarctation



Palpation : Pulses

• Rate

• Regularity

• Quality : – Rate of rise

– Pulse volume

• Fast & brisk : VSD, MR

• Fast & large: PDA, AR, severe anemia



Palpation: Pulses

Simultaneous palpation of

peripheral pulses –

delay in lower extremities is

suggestive of coarctation



Abnormal Pulses

• Pulsus paradoxus – > 10 mmHg difference inSBP during expiration &inspiration

– Seen in constrictivepericarditis,cardiac

tamponade

• Pulsus alternans – Traube’s sign

– Alternating strong & weakpulses

– Severe LV failure



Blood Pressure

• Can be uncomfortable

• Cuff size : inflatablerubber bag covers 2/3of upper arm ; widthhalf of upper armcircumference ;smaller bag – falselyelevated BP



Blood Pressure

• Systolic BP : 1st Korotkoff

sound

• Diastolic BP : 5th

Korotkoff sound• BP lower extremities >

upper by 10 mm Hg

normally ; if

upper > lower by 10 mm

Hg , coarctation of aorta

Normal BP by Sex & Age



HEART MURMURS

• Timing

• Intensity

• Duration / Type• Location



HEART MURMURS

• Timing

– Systolic

– Diastolic

– Systolic-diastolic

– Continuous

S1 S2 S1



HEART MURMURS

• Intensity: Grade I-VI

• Significant: Grade III or louder

• Duration: short or longType: systolic ejection

pansystolic/holosystolic

• SEM - obstruction• HSM - regurgitation



HEART MURMURS

Location

RUSB LUSB

LPSB

APEX



HEART MURMURS

Ejection

AS PS/ASD



HEART MURMURS

Holosystolic

VSD/TR

MR



HEART MURMURS

Base - Congenital

Apex - Acquired



Heart Disease Screening

The 3-minute assessment (GAp CApE)

1. General Appearance - GAp2. Chest Examination - C

3. Abdominal Palpation - Ap

4. Extremity Examination - E



General Appearance (30 seconds)

• Cyanotic or not?

• Facies?

• Tachypnea/Dyspnea/Diaphoretic?

• Failure to thrive?



Chest Evaluation (1 minute 30 seconds)

• Subcostal retraction?

• Apex beat displacement/precordium?

• Murmur?• Rales ?



Abdominal Palpation (20 seconds)

• Liver enlarged?

• On the left?



Extremity Examination (40 seconds)

• Skin - smooth & dry or clammy?

• Pulses - Both upper – equal?

Both lower – equal?

• Capillary refill?

• Clubbing?



Documents

Approach to the Diagnosis of Heart Diseases 2