Pediatric Cardiology Problems Facing the Primary Care ...

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Pediatric Cardiology Problems Facing the Primary Care ...

  1. 1. William F. Waltz, Ph.D., M.D. Pediatric Cardiology Problems Facing the Primary Care Provider Nurse Practitioner Association of South Dakota Fall Conference 5 November 2009
  2. 2. Objectives <ul><li>Discuss recognizing cardiac disease in the primary care setting </li></ul><ul><li>Describe cardiac evaluation by the primary care provider </li></ul><ul><li>Explain when to refer to Pediatric Cardiology </li></ul>
  3. 3. Common “Cardiac” Problems <ul><li>Chest pain </li></ul><ul><li>Syncope </li></ul><ul><li>Hypertension </li></ul><ul><li>Murmur </li></ul><ul><li>Family history </li></ul>
  4. 4. The Plan <ul><li>Discuss common pediatric cardiology referrals for non-cardiac problems </li></ul><ul><li>Compare non-cardiac complaints with serious cardiac issues </li></ul>
  5. 5. <ul><li>Chest pain </li></ul><ul><li>Syncope </li></ul>
  6. 6. Case -Chest Pain <ul><li>A 13 year old boy complains of sharp chest pain at the mid left sternal border that came on during cross country running. </li></ul><ul><li>Stopped running because of the pain. He was short of breath, had tingling hands and feet. </li></ul><ul><li>Pain was worse with a deep breath. </li></ul><ul><li>Physical Exam - BP 110/60 P 90 R 16 - Pulses strong and equal - 2/6 ejection murmur at LUSB - Discrete tenderness at site of pain </li></ul>
  7. 7. Chest Pain <ul><li>Common reason for referral </li></ul><ul><li>Do not equate adult CP with childhood CP </li></ul><ul><li>If benign; reassure, don’t refer </li></ul><ul><li>If suspect cardiac -don’t echo -please refer </li></ul>
  8. 8. Chest Pain Breakdown <ul><li>Idiopathic: 12-85% </li></ul><ul><li>Chest wall/musculoskeletal: 15-95% </li></ul><ul><li>Psychogenic : 20-29% </li></ul><ul><li>Respiratory: 12-21% </li></ul><ul><li>Gastrointestinal: 4-7% </li></ul><ul><li>Cardiac: 1-6% </li></ul><ul><li>Organic and functional causes can coexist </li></ul><ul><li>Non-cardiac chest pain typically occurs at rest -can be worse with movement/exercise, deep inspiration, palpation </li></ul>
  9. 9. <ul><li>Chest wall pain -precordial catch syndrome *sharp pain at rest *worse with deep breath *localized over precordium *lasts seconds to minutes -costochondritis -pleuritis -trauma </li></ul><ul><li>Other non-cardiac; SS crisis, Asthma, Zoster, Pneumonia, GI reflux, Pneumothorax </li></ul>Chest Pain Breakdown
  10. 10. Chest Wall Pain <ul><li>Common in teen athletes </li></ul><ul><li>Frequently seen in association with handsprings, shooting baskets, volleyball, weight lifting, martial arts </li></ul><ul><li>Often comes on as new activity starts </li></ul><ul><li>Frequently worse with deep breathing </li></ul><ul><li>Discrete tenderness over site (sometimes) </li></ul><ul><li>Acute at first, can last for weeks, migrate </li></ul>
  11. 13. Therapy for Chest Wall Pain <ul><li>Reassurance </li></ul><ul><li>NSAIDs: scheduled dose for two weeks </li></ul><ul><li>Avoid offending activity </li></ul><ul><li>Referral for reassurance? </li></ul>
  12. 14. Counseling About Chest Wall Pain <ul><li>Time well spent in evaluation </li></ul><ul><li>Discuss mechanism for pain </li></ul><ul><li>Pain is real, but not a threat </li></ul><ul><li>Pain not due to heart! </li></ul>
  13. 15. <ul><li>cardiac cause in 1-6% </li></ul><ul><li>patients c/o having a heart attack (44%), heart disease (12%), cancer (12%). </li></ul><ul><li>adolescents more likely to have psychogenic chest pain with stress </li></ul><ul><li>younger children more likely to have true cardiorespiratory cause </li></ul>Chest Pain Of Concern
  14. 16. <ul><li>Myocarditis/Cardiomyopathy -associated with GI/Respiratory symptoms -associated with fever, or recent history of fever -appear ill, tachycardia, weak </li></ul><ul><li>Chest pain with exercise should be evaluated before activity continues </li></ul><ul><li>React quickly if patient has known or suspected Marfan’s and tearing chest pain or back pain </li></ul>Chest Pain Of Concern
  15. 17. <ul><li>Pericarditis: lean forward for comfort, friction rub, distended neck veins, hepatomegaly, pulsus paradoxus, low voltage EKG, diffuse ST changes </li></ul><ul><li>Arrhythmias -May be felt as or described as chest pain </li></ul><ul><li>-eg. SVT: sudden on/off, >200/min at rest pallor, hypotension, syncope narrow complex tachycardia on EKG </li></ul><ul><li>-eg. VT: chest pain and syncope 120-240/min </li></ul>Chest Pain Of Concern
  16. 18. <ul><li>Respiratory -asthma -pneumonia/effusion -spontaneous pneumothorax </li></ul><ul><li>Cancer -primary -metastasis/infiltration </li></ul><ul><li>Trauma </li></ul>Chest Pain Of Concern
  17. 19. <ul><li>frequency </li></ul><ul><li>duration: seconds, minutes, hours </li></ul><ul><li>location: sternum, apex, subxiphoid, right, left, diffuse, “point with one finger”, epigastric </li></ul><ul><li>quality: burning, stabbing, sharp, dull, crushing, tearing </li></ul><ul><li>clustering </li></ul><ul><li>setting </li></ul>Taking a Chest Pain History describing the pain
  18. 20. <ul><li>time of day </li></ul><ul><li>relation to meals </li></ul><ul><li>precipitating factors </li></ul><ul><li>exacerbating factors </li></ul><ul><li>relieving factors </li></ul><ul><li>association with rest, body position, deep inspiration </li></ul><ul><li>recent trauma </li></ul>Taking a Chest Pain History describing the pain
  19. 21. <ul><li>Palpitations: fast, slow, irregular, skips, hard </li></ul><ul><li>headaches </li></ul><ul><li>shortness of breath/dyspnea -wheeze/ cough -prolonged expiration -”can’t get air out” -response to bronchodilators </li></ul><ul><li>paresthesias </li></ul>Taking a Chest Pain History associated symptoms
  20. 22. <ul><li>syncope </li></ul><ul><li>near syncope </li></ul><ul><li>dizziness </li></ul><ul><li>sensation of impending doom </li></ul><ul><li>Anginal chest pain: cardiac ischemia in a child produces pain similar to that in adults </li></ul><ul><li>History of Kawasaki with abnormal coronaries </li></ul>Taking a Chest Pain History associated symptoms
  21. 23. <ul><li>Family history </li></ul><ul><li>Social History/Social Dynamic </li></ul>Taking a Chest Pain History
  22. 24. <ul><li>Full Examination </li></ul><ul><li>FOCUSED ON </li></ul><ul><li>Vital signs </li></ul><ul><li>murmurs, rubs, clicks, rhythm, abnormal pulses, abnormal heart sounds </li></ul><ul><li>Lung exam </li></ul><ul><li>Palpation of chest, gentle sternum compression </li></ul><ul><li>Reproducing the chest pain by compression or palpation is very reassuring </li></ul>Physical Exam For Chest Pain
  23. 25. <ul><li>Laboratory studies non-contributory </li></ul><ul><li>EKG if indicated: normal is reassuring almost all HCM have abnormal EKG (LVH) almost all coronary anomalies have abnormal EKG (LVH, ST changes, precordial T wave changes) </li></ul><ul><li>Chest radiograph if indicated -cardiomegaly, abnormal aortic root </li></ul><ul><li>Consider referral </li></ul><ul><li>Echocardiogram </li></ul><ul><li>Holter Monitor </li></ul><ul><li>Event monitor </li></ul><ul><li>Exercise test: if symptoms with exercise </li></ul>Testing/Labs For Chest Pain
  24. 26. SYNCOPE True or False False All syncope is cardiac until proven otherwise
  25. 27. Case -Syncope <ul><li>A 13 year old girl passed out in the shower the morning after a basketball game </li></ul><ul><li>Felt dizzy, vision went black </li></ul><ul><li>Woke up on shower floor </li></ul><ul><li>She says she drinks enough fluid </li></ul><ul><li>Physical Exam - sitting: BP 115/70 P 60 R 16 - standing: BP 95/65 P 90 R 16 - Pulses strong and equal - 2/6 ejection murmur at LUSB - lean, healthy looking </li></ul>
  26. 28. <ul><li>Definition: temporary loss of consciousness due to lack of cerebral perfusion </li></ul><ul><li>Most frequent cause is vasovagal =vasodepressor = neurocardiogenic </li></ul>SYNCOPE
  27. 29. VASODEPRESSOR SYNCOPE <ul><li>Bezold-Jarisch reflex </li></ul>mechanoreceptors C fibers vigorous contractions venous return blood pressure baroreceptors vagus activity sympathetic activity Blood Pressure catecholamines sympathetics heart rate contractility vascular tone
  28. 30. <ul><li>The possibility of serious injury during a faint precludes considering recurrent syncopal episodes of any cause as benign. </li></ul><ul><li>(Gutgesell, AFP, 1997) </li></ul>SYNCOPE
  29. 31. <ul><li>Abnormalities of blood pressure control (common) </li></ul><ul><li>Cardiac abnormalities (uncommon) </li></ul><ul><li>Metabolic abnormalities (rare) </li></ul><ul><li>Seizure disorders (rare with just syncope) </li></ul><ul><li>Psychiatric conditions (rare) </li></ul><ul><li>Drugs (rare) </li></ul>Causes of Syncope
  30. 32. <ul><li>Usually teenagers (13 years +/- 3) </li></ul><ul><li>2.3 female: 1 male (Balaji, ACC, 1994) -may be associated with menstrual cycle </li></ul><ul><li>Usually some precipitating factor -dehydration/underhydration *illness, heat (shower) -poor physical condition -more common in morning </li></ul><ul><li>-fasting </li></ul><ul><li>-prolonged standing/position change to more upright -can occur standing or sitting -fright/anger/stress/sight of blood/smells/injury -cough, voiding, hair grooming </li></ul>Typical Vasovagal Syncope The Setup
  31. 33. <ul><li>Disorientation/feeling of warmth/dizziness </li></ul><ul><li>Nausea </li></ul><ul><li>Visual changes: field narrowing, blurring, spots, dark </li></ul><ul><li>Loss of hearing/rushing noise </li></ul><ul><li>Weakness </li></ul><ul><li>Pallor/clammy skin/sweating </li></ul><ul><li>Going to ground </li></ul><ul><li>May be followed by tonic-clonic movement </li></ul><ul><li>No incontinence </li></ul><ul><li>Resolves within a minute </li></ul><ul><li>Wake up: may be groggy, not post-ictal </li></ul><ul><li>May feel tired for hours </li></ul>Typical Vasovagal Syncope The Event
  32. 34. <ul><li>If the history is typical for simple vasovagal syncope, a careful physical examination is generally the only evaluation required. (Gutgesell, AFP, 1997) </li></ul><ul><li>Recurrence rate 7% at one year, 15% at two years (Ruiz, Am Heart J, 1995) </li></ul>Typical Vasovagal Syncope
  33. 35. Treatment of Vasovagal Syncope <ul><li>Reassurance </li></ul><ul><li>Hydration: 90% effective (Younoszai, Arch Ped Adol Med, 1998) -”Eight 8 ounces glasses/day” +/- two gallons -Urine should look like water -Never thirsty </li></ul><ul><li>Salt </li></ul><ul><li>Avoid caffeine </li></ul><ul><li>Activity restrictions? </li></ul><ul><li>G-maneuvers </li></ul><ul><li>Medications: fludrocortisone, SSRI, beta-blockers, alpha agonists (pseudoephedrine) </li></ul><ul><li>Pacing? </li></ul>
  34. 36. Evaluation of Syncope <ul><li>Complete history </li></ul><ul><li>Complete physical examination </li></ul><ul><li>Careful attention to heart rhythm </li></ul><ul><li>Orthostatic blood pressures? </li></ul><ul><li>EKG </li></ul>
  35. 38. When is syncope concerning? <ul><li>Palpitations/heart rate irregularities </li></ul><ul><li>Syncope with no prodrome </li></ul><ul><li>Frequent syncope </li></ul><ul><li>Exercise-induced syncope </li></ul><ul><li>Family history of recurrent syncope </li></ul><ul><li>Family history of sudden death </li></ul><ul><li>Outflow tract obstruction: HCM </li></ul><ul><li>Myocardial dysfunction: myocarditis, dilated cardiomyopathy, ARVD </li></ul><ul><li>Coronary ischemia </li></ul><ul><li>Cardiac arrhythmias </li></ul>
  36. 39. Other Causes of Syncope <ul><li>Breath Holding Spell </li></ul><ul><li>Respiratory Syncope </li></ul><ul><li>Hyperventilation Syndrome </li></ul><ul><li>Neurologic/Seizures/Migraines </li></ul><ul><li>Emotional/Psychiatric </li></ul>
  37. 40. Hypertension
  38. 41. Definition of Pediatric Hypertension <ul><li>blood pressure >95% on three separate occasions </li></ul>
  39. 42. It’s Out There <ul><li>Based upon the Framingham study, pediatric patients with hypertension are at risk for catastrophic events later in life </li></ul><ul><li>10,641 Dallas children: 1.6% HTN on 3 screens </li></ul><ul><li>6,622 Muscatine children:1% HTN on 4 screens </li></ul><ul><li>3,537 Harlem children: 1% HTN </li></ul><ul><li>Overall Prevelance: 0.5-2% children have significant HTN </li></ul>
  40. 43. <ul><li>Primary HTN -most common cause -usually no symptoms </li></ul><ul><li>Secondary HTN: 74% renal/renal-vascular 19% coarctation 7% others: endocrine -many are in medical care for other issues -BP usually more elevated than in primary HTN </li></ul>It’s Out There
  41. 44. Blood Pressure Control
  42. 45. <ul><li>HTN as child </li></ul><ul><li>Heredity </li></ul><ul><li>Obesity </li></ul><ul><li>Race </li></ul><ul><li>Dietary cations </li></ul><ul><li>Exercise, stress, anxiety </li></ul><ul><li>Smoking </li></ul><ul><li>Alcohol and drugs </li></ul><ul><li>Pregnancy-induced HTN </li></ul><ul><li>Diabetes </li></ul><ul><li>Uric acid </li></ul><ul><li>LV mass </li></ul>Influences on Blood Pressure Childhood Risk Factors for Later-Life Hypertension
  43. 46. <ul><li>Obesity: prevalence of all forms of HTN in adults correlated with tip quintile for fatness 15 years earlier </li></ul><ul><li>Race: Prevalance of HTN in black adults (27%) is twice that of white adults -Kids not as clear </li></ul><ul><li>Dietary: sodium: trend to higher BP potassium: trend to lower BP calcium: trend to lower BP </li></ul><ul><li>Exercise, stress, anxiety: -regular exercise decreases blood pressure -stress/anxiety raise blood pressure -difficult arithmetic, reaction time tasks, video games </li></ul>Influences on Blood Pressure Childhood Risk Factors for Later-Life Hypertension
  44. 47. <ul><li>Smoking: duh </li></ul><ul><li>Alcohol and Meds alcohol: heavy (>3 drinks/day) intake increases BP light (1-2 drinks/day) might be beneficial not recommended for kids several medications can increase BP sympathomimetics, anticonvulsants, OCP, cyclosporine, steroids caffeine, illicit drugs </li></ul><ul><li>Pregnancy-induced HTN: predictor of later HTN in the pregnant one and her baby </li></ul>Influences on Blood Pressure Childhood Risk Factors for Later-Life Hypertension
  45. 48. <ul><li>Diabetes HTN in pediatric diabetes unusual, but happens ie. coexisting conditions strong predictor for adult HTN </li></ul><ul><li>Uric Acid: elevated levels correlate with increased risk of HTN in kids and adults -marker for HTN, not a cause -correlates with plasma renin activity </li></ul><ul><li>Increased left ventricular mass: end organ damage </li></ul>Influences on Blood Pressure Childhood Risk Factors for Later-Life Hypertension
  46. 49. Cardiac Hypertension <ul><li>Coarctation of the aorta </li></ul>
  47. 50. Coarctation of the Aorta
  48. 51. Coarctation of the Aorta
  49. 52. Balloon Angioplasty for Coarctation
  50. 53. Stenting for Coarctation
  51. 54. Coarctation - Surgery
  52. 55. Coarctation
  53. 56. HTN in Coarctation <ul><li>Kidneys downstream from obstruction -increased renin-angiotensin-aldosterone activity </li></ul><ul><li>Baroreceptors upstream from coarctation -reset to higher pressures </li></ul><ul><li>Intrinsic abnormality of aortic tissue </li></ul><ul><li>*lifelong issues </li></ul>
  54. 57. Picking up a Coarctation <ul><li>EXAM! </li></ul><ul><li>elevated blood pressure </li></ul><ul><li>decreased femoral pulses </li></ul><ul><li>upper to lower extremity BP gradient </li></ul><ul><li>non-innocent murmur </li></ul>
  55. 58. Renal Disorders Causing Hypertension Renal Parenchyma Renovascular <ul><li>Acute glomerulonephrtitis renal artery thrombosis pyelonephritis sickle cell crisis HUS vasculitis renal trauma ureteral obstruction </li></ul><ul><li>Chronic glomerulonephrtitis fibromuscular dysplasia pyelonephritis renal artery aneurysm HUS arteriovenous fistula reflux nephropathy vasculitis obstructive uropathy polycystic diseases renal dysplasia renal tumors </li></ul>
  56. 59. Vital Signs Measuring Blood Pressure <ul><li>Patient sitting or supine-be consistent </li></ul><ul><li>Right arm </li></ul><ul><li>Arm flexed </li></ul><ul><li>Relaxed (if possible) </li></ul><ul><li>Right arm & right leg pressures can help </li></ul>
  57. 61. <ul><li>Method 1 : Dynamap = random number generator </li></ul><ul><li>Method 2 : Sphygmomanometer Inflate cuff to 30mmHg above expected BP Deflate 3mmHg/sec </li></ul><ul><li>Method 3 : Sphygmomanometer Inflate cuff until radial pulse disappears Deflate 3mmHg/sec </li></ul><ul><li>Method 4 : Direct catheter measurement </li></ul>Vital Signs Measuring Blood Pressure
  58. 62. <ul><li>Method 3 : Sphygmomanometer </li></ul><ul><li>Inflate cuff until radial pulse disappears </li></ul><ul><li>Deflate 3mmHg/sec </li></ul>Vital Signs Measuring Blood Pressure Best Method
  59. 63. Vital Signs Korotkoff Sounds Korotkoff sounds = sounds produced by blood flowing past deflating cuff Korotkoff sounds first heard at all Korotkoff sounds consistently heard = systolic BP Korotkoff sounds get softer Korotkoff sounds get suddenly softer Korotkoff sounds disappear = diastolic BP Korotkoff sounds get louder 80mmHg 120mmHg
  60. 64. Blood Pressure Assessment <ul><li>Measure blood pressure -if abnormal, -history and exam -repeat on another occasion </li></ul><ul><li>Repeat blood pressure -if still high (90-95%) -talk about lifestyle issues -repeat in six months -if still high (>95%), work it up </li></ul>
  61. 65. Detecting HTN in Children <ul><li>Measure BP upon admission to the nursery </li></ul><ul><li>Measure BP at every well child check and annual physical </li></ul><ul><li>Measure BP at other visits, if possible </li></ul><ul><li>Also, do a good cardiac exam at each check and physical </li></ul><ul><li>Also, do a good cardiac exam when guided by symptoms </li></ul><ul><li>Pursue evaluation when indicated </li></ul>
  62. 66. Treatment of HTN in Children <ul><li>PREVENTION </li></ul><ul><li>Make accurate measurements </li></ul><ul><li>Make accurate diagnosis </li></ul><ul><li>Treat underlying condition, if possible </li></ul><ul><li>Weight control </li></ul><ul><li>Low fat-high fiber diet </li></ul><ul><li>Sodium restriction </li></ul><ul><li>Exercise </li></ul><ul><li>Relaxation </li></ul><ul><li>Avoid alcohol, medications, drugs, caffeine </li></ul><ul><li>No tobacco </li></ul>
  63. 67. Meds for HTN in Children <ul><li>Goal is normal pressures </li></ul><ul><li>Individualized approach, not stepped-care </li></ul><ul><li>Start with single drug therapy -ACE inhibitors -beta blockers -calcium channel blockers -diuretics *lowest effective dose </li></ul><ul><li>Add additional med if needed </li></ul><ul><li>Management is usually long-term </li></ul>
  64. 68. Summary <ul><li>Pediatric hypertension is uncommon but real </li></ul><ul><li>Pediatric hypertension must be diagnosed and fully evaluated </li></ul><ul><li>Pediatric hypertension must be treated for short and long term gain </li></ul><ul><li>Refer to nephrology, cardiology, endocrinology as indicated </li></ul>
  65. 69. <ul><li>Murmurs </li></ul>
  66. 70. <ul><li>Intensity (grade) </li></ul><ul><li>Pitch </li></ul><ul><li>Timing </li></ul><ul><li>Location </li></ul><ul><li>Radiation </li></ul><ul><li>Quality </li></ul>Auscultation Murmurs
  67. 71. <ul><li>Grade 1 = faint </li></ul><ul><li>Grade 2 = soft </li></ul><ul><li>Grade 3 = loud </li></ul><ul><li>Grade 4 = loud with thrill </li></ul><ul><li>Grade 5 = heard with edge of stethoscope </li></ul><ul><li>Grade 6 = heard with stethoscope off chest </li></ul>Auscultation Murmurs- Intensity
  68. 72. <ul><li>Pitch = frequency </li></ul><ul><li>High </li></ul><ul><li>Medium </li></ul><ul><li>Low </li></ul><ul><li>Reflects velocity of jet </li></ul><ul><li>Reflects pressure gradient driving the jet </li></ul>Auscultation Murmurs-Pitch
  69. 73. So Much Noise
  70. 74. <ul><li>Systolic: S1-coincident, early, mid, late </li></ul><ul><li>Diastolic: early, mid </li></ul><ul><li>Continuous </li></ul>Auscultation Murmurs-Timing
  71. 75. <ul><li>Remember aortic, pulmonary, mitral, tricuspid areas for the tests </li></ul><ul><li>Be wary of abnormal anatomy </li></ul><ul><li>Describe location on chest </li></ul>Auscultation Murmurs-Location
  72. 76. NL
  73. 77. <ul><li>Listen everywhere! </li></ul><ul><li>Determine if you hear radiation of one murmur or a different murmur </li></ul><ul><li>Some may change pitch as you get further from focus </li></ul>Auscultation Murmurs-Radiation
  74. 78. <ul><li>Crescendo </li></ul><ul><li>Decrescendo </li></ul><ul><li>Crescendo-decrescendo </li></ul><ul><li>Be creative: blowing harsh </li></ul><ul><li>coarse </li></ul><ul><li>honking </li></ul><ul><li>squeak </li></ul>Auscultation Murmurs-Quality
  75. 79. ABNORMAL SYSTOLIC MURMURS
  76. 80. DIASTOLIC MURMURS eg. Flow Rumble
  77. 81. Vital Signs <ul><li>Weight </li></ul><ul><li>Height </li></ul><ul><li>Blood pressure </li></ul><ul><li>Heart rate -compare with age norms -consider patient’s physiologic state </li></ul><ul><li>Respiratory rate -compare with age norms </li></ul><ul><li>-consider patient’s physiologic state </li></ul><ul><li>Temperature </li></ul><ul><li>Oxygen saturation </li></ul>
  78. 82. General <ul><li>Well-nourished? </li></ul><ul><li>Well-developed? </li></ul><ul><li>Syndromic? </li></ul><ul><li>Deformities? </li></ul><ul><li>Distress? </li></ul><ul><li>Respiratory effort? </li></ul><ul><li>Level of consciousness? </li></ul><ul><li>Pallor/cyanosis? </li></ul><ul><li>Anxiety? </li></ul>
  79. 83. Inspection <ul><li>Precordium activity </li></ul><ul><li>Neck pulses </li></ul><ul><li>Chest deformity </li></ul><ul><li>Respiratory effort </li></ul><ul><li>Head bobbing </li></ul>
  80. 84. Inspection <ul><li>Skin color/tone/texture </li></ul><ul><li>Scars </li></ul><ul><li>Rashes </li></ul><ul><li>Vein distension </li></ul><ul><li>Jugular venous distension </li></ul><ul><li>Carotid thrill </li></ul><ul><li>Cranial thrill </li></ul>
  81. 85. Rashes may point to the heart
  82. 86. Palpation and Percussion <ul><li>Precordium activity: quiet, active, hyperdynamic </li></ul><ul><li>PMI (point of maximal impulse) </li></ul><ul><li>Lifts, heaves, taps </li></ul><ul><li>Palpable heart sounds </li></ul><ul><li>Thrills </li></ul><ul><li>The heart should percuss to the PMI </li></ul>
  83. 87. Auscultation Principles and Technique <ul><li>GET A GOOD STETHOSCOPE!!!!!!!!! </li></ul><ul><li>Become one with the stethoscope </li></ul><ul><li>Eliminate extraneous noise </li></ul>
  84. 88. <ul><li>Breathing normally -breath hold helps </li></ul><ul><li>Listening for heart sounds radiating to the back </li></ul><ul><li>Listening for abnormal vascular sounds </li></ul><ul><li>Listen on sides of chest and axillae </li></ul>Auscultation Start with the back
  85. 89. <ul><li>Standard lung exam </li></ul><ul><li>Lung findings may not represent primary lung pathology </li></ul><ul><li>Crackles may mean pulmonary vascular congestion </li></ul><ul><li>Wheezing may be due to severe pulmonary congestion </li></ul><ul><li>Percuss for effusions </li></ul>Auscultation Lung Sounds
  86. 90. Abdomen <ul><li>Inspection: distension, veins </li></ul><ul><li>Auscultation: bowel sounds bruit </li></ul><ul><li>Palpation: liver size: breadth, liver edge, tender splenomegaly pulsatility mass </li></ul>
  87. 91. Palpating Pulses <ul><li>Brachial/radial </li></ul><ul><li>Femoral </li></ul><ul><li>*at same time! </li></ul><ul><li>pedal </li></ul><ul><li>popliteal </li></ul><ul><li>axillary </li></ul>
  88. 92. Extremities <ul><li>perfusion </li></ul><ul><li>edema </li></ul><ul><li>clubbing </li></ul><ul><li>deformity </li></ul>
  89. 93. Clubbing
  90. 94. Endocarditis Janeway lesions Splinter hemorrhages Osler’s nodes Roth spots
  91. 95. Family History <ul><li>We already talked about it…and more to come </li></ul>

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