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Acid Reflux causes and Treatment

“Cardiac History and Exam” by Christina Ronai for OPENPediatrics

“Cardiac History and Exam” by Christina Ronai for OPENPediatrics


Cardiac History and Exam with Christina Ronai. Hi, my name is Christina Ronai. I’m one of
the Cardiology Fellows at Boston Children’s Hospital and I’ll be talking to you today
about the cardiac history and physical exam when evaluating children for possible cardiac
disease. Our objectives today are to understand the
clinical history relevant to heart disease in children, recognize the features of the
clinical exam in heart disease, understand the basics of auscultation and characterization
of cardiac murmurs, and understand the features of pathologic versus benign murmurs. Clinical History. From a history standpoint, there are three
important categories: gestational and perinatal history, especially if evaluating an infant,
postnatal and present history, and then family history. We’re going to go through each of
these. The gestational and perinatal history is really
important when evaluating an infant. Specifically, you’re going to want to ask about the maternal
history. Were they healthy while they were pregnant? Did they receive prenatal care?
And did they have regular ultrasounds during pregnancy? And if so, did those show anything
of concern? When you’re asking about maternal infections,
you’re referring mostly to the TORCH infections, but any infection is also important to note.
Finally, you’re going to ask if mom took any medications. Specifically, phenytoin, lithium,
retinoic acid, and warfarin have all been associated with cardiac malformations. The postnatal and present history is our next
category. Most importantly for infants and young children is are they growing along their
growth curve? And if they’re not growing along their growth curve, have they at least continued
to consistently gain weight or have they been losing weight? Are they meeting their developmental
milestones? Have there been any feeding problems? Is there any cyanosis? Decreased exercise tolerance. Specifically
for young children, you’re going to want to ask, as they run around on the playground,
are they able to keep up with their peers or are they falling back? Have they ever fainted
or felt as if they were about to faint? Have they ever experienced chest pain or palpitations?
When you’re asking about palpitations, I usually pose the question to children have they had
any extra beats or skipped beats? The most important thing to remember when
evaluating an infant is that feeding is really an exercise test for them. And if they are
able to feed and grow, there’s usually not a major cardiac issue. Family history. You’re going to want to ask
if anyone has ever been born with a heart problem. And that’ll be your screening for
family history of congenital heart disease. Has anyone passed away suddenly or from an
unexplained cause? Often I will also ask about unexplained car accidents or drownings, because
those can be indicative of electrical problems with the heart. Does anyone have hypertrophic
or dilated cardiomyopathy? And does anyone in the family require a pacemaker or an implanted
defibrillator? Clinical Exam. Next, we’re going to move to the physical
exam. The most important thing when you walk in the room is to take in the general appearance
of the infant or child. From a nutritional standpoint, do they look
well nourished or are they malnourished? In terms of their respiratory status, are they
breathing easily or are they breathing quickly and with difficulty? Then you’re going to turn to palpation from
the cardiac perspective. You’re going to put your hand on their chest and feel their precordium
to see if they are hyperdynamic, is the point of maximal impulse displaced, and do you feel
a thrill? Then you’re going to turn to peripheral pulses. In an infant, it’s going to be really important
to feel for the upper brachial pulse and the lower femoral pulses. And note, are they bounding
or is there a difference between the upper and lower pulses? In addition, you’re going
to want at this point turn to the blood pressure, which should in an infant or young child have
been taken in both an upper extremity and a lower one to make sure that there’s no gradient. Point of clarification. A systolic blood pressure
measurement of greater than 10 millimeters of mercury higher in the arm than the leg
may signify the presence of a coarctation of the aorta. Then you’re going to turn to auscultation. Auscultation refers to the appreciation of
the heart sounds. It’s important to remember that there are two big heart sounds, S1 and
S2. S1 is going to refer to the mitral and tricuspid valve closure. And S2 to the aortic
and pulmonary valve closure. People often talk about the splitting of S2. In normal
children, it is normal to hear a variation in the splitting with respiration. [HEART BEATING] Abnormal Heart Sounds. Abnormal splitting refers to when the S2 sounds
are widely split, and that can be reflective of volume overload or electrical delay in
a right bundle branch block. [HEART BEATING] Narrowly split second heart sounds usually
are reflective of pulmonary hypertension or aortic stenosis. [HEART BEATING] And if the second heart sound is entirely
single, that is reflective of severe aortic stenosis, or pulmonary hypertension. [HEART BEATING] This is a useful diagram for referring to
the different areas that you’ll listen to the valves opening and closing. As you can
see, there is an appropriate place to listen for both the mitral, the tricuspid, and then
the aortic, and the pulmonic. Murmurs. Murmurs are the sound of blood moving
through the heart. It’s important to remember that those can be benign, as in the sound
of blood moving through an entirely structurally normal heart, or the sound made by blood moving
through abnormal valves or holes in the heart. Murmurs are broken down into systolic, diastolic,
continuous, gallops, and clicks. We will go through each of these. Before we do that, it’s important to remember
that we grade murmurs and that we are standardized across all specialties into how we grade the
murmurs. Grade I is barely audible. Grade II is soft but easily audible. A grade III
is moderately loud but accompanied by no thrill when you put your hand on the precordium.
Grade IV is loud and has a thrill. Grade V is audible with the stethoscope barely on
the chest, and grade VI is audible with the stethoscope off the chest and very rare. Systolic murmurs are divided into three categories:
ejection, late systolic, and holosystoic. Ejection murmurs are usually reflective of
pulmonary stenosis or aortic stenosis. Late systolic murmurs are usually reflective of
mitral valve prolapse, and holosystolic murmurs are usually tricuspid regurgitation, mitral
regurgitation, or a ventricular septal defect. This is a helpful chart in terms of breaking
down the ways that systolic murmurs sound. In a midsystolic murmur, you can hear that
they’re initially softer, then they get louder and then softer again. Sometimes, that’s referred
to as a crescendo-decrescendo murmur. [HEART BEATING] Holosystolic murmurs are heard throughout
systole between S1 and S2 and can often actually obscure the beginning of diastole. [HEART BEATING] Early systolic murmurs are short and heard
right at the beginning. [HEART BEATING] And late systolic murmurs are usually reflective
of mitral regurgitation and are usually accompanied by a mitral click. [HEART BEATING] Diastolic murmurs are always pathologic. They
are broken into early diastolic and mid-diastolic. Early diastolic murmurs are usually higher
pitched and are reflective of aortic regurgitation if it radiates to the apex, or pulmonary regurgitation
if it radiates along the left sternal border. [HEART BEATING] Mid-diastolic murmurs tend to be lower pitched,
are appreciated with the bell of your stethoscope, and they are mitral stenosis, which you hear
at the apex of the heart, or tricuspid stenosis at the left lower sternal border. [HEART BEATING] Continuous murmurs are reflective of a PDA,
an AV fistula, a shunt murmur after surgery, or a venous hum. PDA are Patent Ductus Arteriosis
murmurs and are usually appreciate in newborns before the duct has closed. [HEART BEATING] In addition, shunt murmurs are usually only
heard after a child has had surgery. This is another diagram that is helpful for remembering
where you are going to hear each of the murmurs, so an aortic valve stenosis murmur would be
best appreciated in the aortic valve area, which is in the right upper sternal border.
Pulmonic murmurs are usually heard along the left upper sternal border. Mitral murmurs
are usually heard along the apex, and a VSD or tricuspid regurgitation or Still’s murmurs
are heard at the left lower sternal border. Gallops. Gallops are broken down into either
S3 or S4. The third heart sound is referred to as S3 and is usually heard at the apex
of the heart. Point of clarification. An S3 gallop is best
heard at the apex if produced by a dilated or dysfunctional left ventricle or along the
left lower sternal border if produced by a dilated or dysfunctional right ventricle. [HEART BEATING] It can be normal in children and young adults.
Although, it can also be reflective of patients with dilated ventricles and decreased compliance.
Fourth heart sounds are heard also at the apex, and these are always part pathologic. [HEART BEATING] Point of clarification. An S4 gallop is usually
associated with decreased ventricular compliance that occurs with myocardial ischemia or ventricular
hypertrophy. Clicks. Clicks. There are three types of clicks:
ejection click, mid-systolic click, or the diastolic opening snap. An ejection click
is usually appreciated at the apex of the heart. It is reflective of aortic stenosis,
usually, if there’s a bicuspid aortic valve as well. [HEART BEATING] Mid-systolic clicks are heard at the apex
and usually reflect mitral valve prolapse. [HEART BEATING] Finally, diastolic opening snaps are also
mitral stenosis but are usually heard at the apex or left lower sternal border. [HEART BEATING] Rubs. A pericardial friction rub can be heard
when the two walls of the pericardium rub against each other, producing audible friction.
This sound can be described as a grating, scratching, or rasping noise that sounds similar
to squeaky leather. It has both a systolic and diastolic component and often obscures
the normal S1 and S2 heart sounds. The sound is usually best heard between the apex and
the sternum and can be indicative of pericarditis, which is an inflammation of the fibrous sac
surrounding the heart. [HEART BEATING] Thank you very much for your time today. I
hope that you’ve enjoyed learning about the cardiac history and physical exam. Please help us improve the content by providing
us with some feedback.

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