2. INCIDENCE OF CHD
6 PER 1000 LIVE BIRTHS
- FOR MODERATE AND SEVERE FORMS OF CHD.
19 PER 1000 LIVE BIRTHS
- IF POTENTIALLY SERIOUS BICUSPID AORTIC VALVE IS
INCLUDED.
75 PER 1000 LIVE BIRTHS
-IF VERY SMALL MUSCULAR VSDS ARE INCLUDED.
3. CLINICAL DIAGNOSIS OF CHD
REPRESENTS THE EPITOME OF APPLIED LOGIC.
DIAGNOSES EMERGE WITH GRATIFYING
FREQUENCY WHEN CORRECT INFERENCES
ARE DRAWN FROM ACCURATE OBSERVATIONS.
IT IS A STIMULATING CHALENGE AND A
CONSTANT SOURCE OF SELF EDUCATION.
4. CLINICAL CLASSIFICATION OF CONGENITAL
HEART DISEASE
1.ACYANOTIC WITHOUT A SHUNT (NORMAL OR DECREASED
PULMONARY ARTERIAL BLOOD FLOW)
A.MALFORMATIONS ORIGINATING IN THE RIGHT SIDE OF THE HEART
(FROM MOST PROXIMAL TO MOST DISTAL.)
B.MALFORMATIONS ORIGINATING IN THE LEFT SIDE OF THE HEART
(FROM MOST PROXIMAL TO MOST DISTAL.)
2.ACYANOTIC WITH A SHUNT
(LEFT TO RIGHT, INCREASED PULMONARY ARTERIAL BLOOD FLOW)
SHUNT AT ATRIAL LEVEL
SHUNT AT VENTRICULAR LEVEL
SHUNT BETWEEN AORTIC ROOT AND RIGHT SIDE OF HEART
SHUNT AT AORTOPULMONARY LEVEL
SHUNT AT MORE THAN ONE LEVEL
5. CLINICAL CLASSIFICATION OF CONGENITAL
HEART DISEASE
CYANOTIC
INCREASED PULMONARY ARTERIAL BLOOD FLOW
NORMAL OR DECREASED PULMONARY ARTERIAL
BLOOD FLOW
DOMINANT LEFT VENRICLE
DOMINANT RIGHT VENTRICLE
WITH PULMONARY HYPERTENSION
WITHOUT PULMONARY HYPERTENSION
NORMAL OR NEARLY NORMAL VENTRICLES.
6. DIAGNOSIS OF CHD- FIVE BASIC QUESTIONS
IS THE PATIENT ACYANOTIC (OR) CYANOTIC?
IS PULMONARY ARTEIAL BLOOD FLOW
INCREASED (OR) NOT ?
DOES THE MALFORMATION ORIGINATE IN THE
LEFT (OR) RIGHT SIDE OF THE HEART ?
WHICH IS THE DOMINANT VENTRICLE ?
IS PULMONARY HYPERTENSION PRESENT (OR)
NOT ?
7. DIAGNOSIS OF CONGENITAL HEART DISEASE
HISTORY
GENERAL EXAMINATION
EXAMINATION OF PRECORDIUM
CHEST SKIAGRAM
ECG
8. HISTORY
DEVELOPMENT AND WEIGHT GAIN
FEEDING DIFFICULTY, TACHYPNEA, DYSPNEA
FREQUENT RESPIRATORY INFECTIONS
CYANOSIS AND CYANOTIC SPELLS, SQUATTING
EXERCISE INTOLERANCE
CHEST PAIN, SYNCOPE, PALPITATIONS
NEUROLOGICAL SYMPTOMS
ANTENATAL HISTORY
FAMILY HISTORY
10. PAROXYSMAL HYPOXIC SPELL
FOUND IN
TETROLOGY OF FALLOT
OTHER DISEASES WITH FALLOT’S PHYSIOLOGY
PULMONARY ATRESIA WITH VSD
COMMENST AGE
4MONTH TO 12 MONTH OF AGE
RARE BEYOND 2YEARS OF AGE
FEAUTURES
OCCURS USALLY IN THE MORNING, AFTER A GOOD SLEEP.
PRECIPITATED BY FEEDING , CRYING & BLADDER AND BOWEL MOVEMENTS
HYPERPNEA INCREASES, CYANOSIS DEEPENS. MAY DEVELOP SYNCOPE -
CONVULSION-CVA
MACHANISMS
INFUNDIBULAR PULMONARY SPASM
OVER REACTION OF IMMATURE RESPIRATORY CENTER.
PARAOXYSMAL ATRIAL TACHYCARDIA.
11.
12. SQUATTING
AGE OF OCCURRENCE
MACHANISMS RIGHT - LEFT SHUNT IS DECREASED DUE TO
1. DECREASED VENOUS RETURN
2. INCREASD SVR DUE TO COMPRESSION OF FEMORAL
ARTERY
SQUATTING EQUIVALENTS
1. KNEE-CHEST POSITION
2. SITTING WITH LEGS DRAWN UNDERNEATH
3. STANDING WITH CROSSED LEGS.
14. SYMPTOM EVALUTION FOR CHD
SYMPTOM
CONGENITAL HEART
DISEASES
EXERTIONAL ANGINA
AS, PS, PPH, ALCOPA
EXERTIONAL SYNCOPE AS, PS.
CYANOSIS WITH SYNCOPE TOF
DYSPHAGIA DOUBLE AORTIC ARCH,
ANOMALOUS ORIGIN OF RIGHT
SUBCLAVIAN ARTERY PASSING
BELOW OESOPHAGUS.
CVA IN A CYANOTIC CHILD
CYANOTIC CHD COMPLICATED BY
CEREBRAL ABSCESS, CEREBRAL
THROMBI & PARADOXICAL
15. ANTENATEL HISTORY
MATERNAL DISEASES CARDIAC MALFORMATIONS IN
THE NEW BORN
MATERNAL RUBELLA
(IN THE FIRST TRIMESTER OF PREGNANCY)
CONGENITAL RUBELLA SYNDROME
- PDA, PERIPHERAL PULMONARY
ARTERY STENOSIS, VPS, ASD.
MATERNAL LUPUS ERYTHMATOSUS CONGENITAL COMPLETE HEART BLOCK
MATERNAL DIABETUS
TGA, VSD, COMMON ATRIUM,
CARDIOMEGALY,CARDIOMYOPATHY
16. ANTENATAL HISTORY – TERATOGENIC
DRUGS
TERATOGENIC
DRUGS
CARDIAC MALFORMATIONS EXTRA CARDIAC
ABNORMALITIES
THALIDOMIDE VARIABLE -TF,VSD,ASD,TA PHOCOMELIA
LITHIUM EBSTEIN'S ANOMALY OF
TRICUSPID VALVE,
TRICUSPID ATRESIA
NONE
ISORETINOIN VSD
ALCOHOL ABUSE FOETAL ALCHOL SYNDROME
- VSD (45% OF INFANTS), PDA, ASD
MICROCEPHALY, GROWTH
AND MENTAL RETARDATION,
SMOOTH PHILTRUM, THIN
UPPERLIP
EPTOIN FOETAL HYDANTION SYNDROME
- PS, AS, COARCTATION OF AORTA,
PDA
MICROCEPHALY, GROWTH
AND MENTAL RETARDATION,
SHORT PALPABERAL
FISSURES, SMOOTH
PHILTRUM, THIN UPPERLIP
17. FOETAL ALCOHOL SYNDROME
AFFECTS 30-40% OF CHILDREN BORN
TO ALCOHOLIC MOTHER
CLINICAL FEATURES
- UNDER DEVELOPED- APPEARING
CENTRL FACE DUE TO
MAXILLARY HYPOPLASIA
- SMALL AND UPTURNED NOSE
- INDISTINCT (OR) SMOOTH PHILTRUM
- MICROGNATHIA
- THIN UPPER LIP AND VERMILON
CARDIAC ANOMALIES
- VSD
- ASD
18. Physical Examination
•
General appearance, weight and nutrition
•
Association with chromosomal syndromes
and other systemic malformations
•
Colour
•
Vital Signs
– Pulse, BP, respiration and temperature
19. GENDER PREDISPOSITION OF CHD
MALE
1. VALVULAR A.S
2. CORACTATION
OFAORTA
3. TGA
4. HYPOPLASTIC LEFT
HEART SYNDROME
5. PULMONARY AND
TRICUSPID ATRESIAS
6. TOF
FEMALE
1. ASD
2. PDA
3. EBSTENIS ANOMALY
OF TRICUSPID VALVE.
20. GENERAL EXAMINATION
GENERAL APEARANCE
1. SHORT STATURE -TURNER SYNDROME, NOONAN SYNDROME,
-ELIS–VAN CREVELD SYNDROME.
2. POORLY DEVELOPED - COARCTATION OF AORTA
LOWER EXTREMITIES
HEAD & FACE
1. HYPERTELORISM
[WIDELY SET EYES] -NOONAN SYNDROME
-TURNER SYNDROME (BCAV, COARC.AORTA)
-MULTIPLE LENTIGENES SYNDROME (P.S, HOCM)
-WILLIAM SYNDROME (SUPRA VALVULAR A.S)
2. WEBBING OF THE NECK -TURNER SYNDROME, NOONAN SYNDROME
3. LOW SET EARS - DOWN SYNDROME, WILLIAM SYNDROME,
- NOONAN SYNDROME
4. LOW POSTERIOR HAIRLINE -TURNER SYNDROME, NOONAN SYNDROME
5. TYPICAL FACIAL APPEARANCE
-MONGOLIAN FACIES -DOWN SYNDROME
- ELFIN FACIES -WILLIAM SYNDROME
22. HYPERTELORISM
ORBITAL HYPERTELORISM
INCREASED OUTER CANTHAL DISTANCE (OR) OUTER INTER
ORBITEL DISTANCE.
OCCULAR HYPERTELORISM
INCREASED IPD.
TELECANTHUS
1. LARGE DISTANCE BETWEEN TWO MEDIAL CANTHI,
WHEN COMPARED TO INTER ORBITAL DISTANCE.
(NORMAL ADULT-30MM)
2. MUSTARDE RATIO
ICD/IPD > 0.55
3. SUSPECTED WHEN LOWER LID PUNCTA IS LATERAL TO THE
MEDIAL EDGE OF IRIS IN STRAIGHT GAZE.
23. LOW SET EAR - MEASUREMENTS
AN IMAGINARY LINE IS DRAWN FROM THE OUTER CANTHUS TO EXTERNAL
OCCIPITAL PROTUBERANCE
(OR)
DRAW A LINE JOINING INNER AND OUTER CANTHUS AND EXTENDING IT.
IF THE SUPERIOR ATTACHMENT OF THE PINNA IS
-AT (OR) ABOVE THIS LINE → NORMAL
-BELOW THIS LINE → LOW SET EARS
24. LOW HAIRLINE - MEASUREMENTS
TWO CRITERIAS
POSTERIOR HAIRLINE IS BELOW
THE
LEVEL OF 5TH
CERVICAL SPINOUS
PROCESS.
RATIO OF
DISTANCE BETWEEN EXT OCCIPITAL
PROTUBERANCE TO POSTERIOR
HAIR LINE &
DISTANCE BETWEEN POSTERIOR
HAIRLINE TO C7 SPINOUS
PROCESS.
= > 1/6 IN MEN
> 1/4 IN WOMEN
25. SHORT NECK
BIRD’S INDEX
RATIO BETWEEN THE HEIGHT AND DISTANCE
BETWEEN THE EXTERNAL OCCEPITAL
PROTRUBERANCES TO THE C7 SPINOUS
PROCESS.
NORMAL RATIO – BELOW 12.8
SHORT NECK IS WHEN THE RADIO IS > 13.6.
26. TURNER SYNDROME
Row 1 Row 2 Row 3 Row 4
0
2
4
6
8
10
12
Column 1
Column 2
Column 3
CHROMOSOMAL PATTERN - 45 XO
CLINICAL FEATURES
-PHENOTYNE- FEMALE, SHORT STATURE,WEBBED
NECK, LOW HAIR LINE,SMALL CHIN
- PROMINENT EARS (LARGE AURICLES)
- BROAD CHEST WITH WIDELY SPECED NIPPLES,
CUBITUS VALGUS, SHORT 4TH METECARPALS
AND METATARSALS, NARROW HYPER CONVEX
NAILS, PIGMENTED NEVI, ABSENT AUXILLARY
AND PUBIC HAIR (OVARIAN DYSGENESIS)
CARDIAC ANOMALIES
- COARCTATION OF AORTA (MORE COMMEN IN
TURNER WITH WEBBING OF THE NECK.)
- BICUSPID AORTIC VALVE WITH AS.
28. EXAMINATION OF EYES
EYES
EXTERNAL APPEARANCE
1. PTOSIS - NOONAN SYNDROME
2. BRUSHFIELD SPOTS - DOWN SYNDROME
3. COLOBOMA OF IRIS - CAT'S EYE SYNDROME (TOF,TRICUSPID
ATRESIA, ASD & VSD)
4. PREMATURE CATARACT – CONGENITAL RUBELLA SYNDROME
INTERNAL APPERANCE
RETINA
1. TORTOUS RETINAL ARTERIES - COARCTATION OF AORTA
WITH 'U' TURNS WITHOUT
CHARACTERISTIC CHANGES
OF HYPERTENSIVE RETINOPATHY
29. CONGENITAL RUBELLA SYNDROME
DUE TO 1ST TRIMESTER MATERNAL
RUBELLA INFECTION
CLINICAL FEATURES
-CONGENITAL CATARACT
-CONGENITAL DEAFNESS
-MENTAL DEFICENCY
- MICROCEPHALY
- PROLEFERATIVE VASCULAR
LESIONS.
CARDIAC ANOMALIES
- PDA , ASD.
- PULMONARY VALVULAR AND
ARTERIAL STENOSIS.
30. EXAMINATION OF MOUTH
MOUTH
LIPS
1. ABSENT PHILTRUM - FOETAL ALCOHOL SYNDROME
2. LONG PHILTRUM - WILLIAM SYNDROME
3. BLUISH DISCOLOURATION - CYANOSIS
MUCUS MEMBRANE
1.CLUSTERS OF SMALL RUBY PATCHES - HERDITARY TELANGIECTASIA
(RENDU – OSLER- WEBER SYNDROME)
TEETH
1. MALFORMED TEETH - WILLIAM SYNDROME
2. PREMATURELY ERUPTED TEETH - ELIS VAN CREVELD SYNDROME
(PRESENT AT BIRTH + GINGIVAL
HYPERTROPHY + MULTIPLE FRENULA
TONGUE
1. LONG PROTRUDING TONGUE - DOWN SYNDROME
2. HIGH ARCHED PALATE - NOONAN SYNDROME
3. CLEFT OF SOFT PALATE - VELOCARDIOFACIAL SYNDROME (VSD)
31. WILLIAMS SYNDROME
NON FAMILIAL SUPRA VALVULAR AS
CLINICAL FEATURES
- FACE IS DIAGNOSTIC
- HEAD IS SMALL (ELF – LIKE APPERANCE)
- CHEEKS ARE FULL AND BAGGY
- MOUTH AND FOREHEAD ARE LARGE
- CURVED LIPS, PEG SHAPED, WIDELY
SPACED TEETH
- MENTAL RETARDATION
CARDIAC ABNORMALITES
- SUPRA VALVULAR AS
- PULMONARY ARTERY BRANCH STENOSIS.
40. HOLT–ORAM SYNDROME
INHERITENCE: - AUTOSOMAL DOMINENT
CLINICAL FEAUTURES
- -HYPOPLASTIC THUMB WITH AN
ACCESSORY PHALANX (TRIPHALANGISM)
--THUMB MAY BE RUDIMENTARY (OR) ABSENT
--METACARPAL BONE MAY BE
SMALL (OR) ABSENT
--HYPOPLASTIC RADIUS.
CARDIAC ANOMALY
- OSTIUM SECUNDOM ASD.
41. ELLIS – VAN CREVELD SYNDROME
INHERITENCE
AUTOSOMAL RECESSIVE
CLINICAL FEATURES
DWARFISM WITH POLYDACTYLY OF THE
HANDS (INVARIABLE)
POLYDACTYLY OF THE FEET (10%)
POLYCARPALY (9 OR 10TH CARPEL BONE)
CLINODACTYLY (BENT FINGERS)
SYNDACTYLY (INTERDIGITAL WEBBING)
HYPOPLASIA OF THE NAILS
PREMATURE ERUPTION OF MALFORMED
MAXILLARY INCISORS; GINGIVAL
HYPETORPHY AND MULTIPLE FRENULA
CARDIAC ANOMALY
COMMON ATRIUM, LARGE ASD.
42. Pulse and BP
•
Examine pulse and BP in all four limbs.
•
Weak lower limb pulses suggestive of
coarctation of aorta.
•
BP compared against age specific percentile
curves.
43. JUGULAR VENOUS PLUSE (JVP)
TOF: INCONSPICUOUS; AGEING , SYSTEMIC HTN, ETC. CAN
PRODUCE PROMINENT A WAVE. POSTOPERATIVE : A AND V
WAVES.
PROMINENT A WAVE: TRICUSPID ATRESIA, PULMONARY
ATRESIA WITH INTACT SEPTUM AND PS WITH STRETCHED
PFO.
EISENMENGER PHYSIOLOGY: PROMINENT A AND V WAVES;
SOMETIMES V WAVE CAN BECOME VERY PROMINENT,
SIMULATING VENOUS CORRIGAN.
TAPVC: PROMINENT V WAVE.
EBSTEIN’S ANOMALY: PROMINENT A AND V WAVES ARE
OCCASIONALLY FOUND DUE TO HYPOKINETIC TR AND
COMMODIOUS RIGHT ATRIUM.
44. EXAMINATION OF THORAX- INSPECTION
1.PRECORDIAL BULGE - CARDIAC ENLARGEMENT BEFORE
PUBERTY.
2.PECTUS EXCAVATUM & CARINATUM - ASD, NOONAN SYNDROME
3.FEMALE HYPOMASTIA - TURNER'S SYNDROME
(SHIELD CHEST)
4.HARRISON'S GROOVE -CHRONIC DYSPNOEA DUE TO LARGE
LEFT TO RIGHT SHUNT LESIONS
5.HEAVY MUSCULAR THORAX WITH - CO–ARCTATION OF AORTA
LESS DEVELOPED EXTREMITES (VISIBLE COLLATERAL ARTERIES IN
45. PALPATION OF PRECORDIUM
THRILL
PS, STRETCHED PFO.
DORV, RESTRICTIVE VSD.
TRICUSPID ATRESIA, PS RESTRICTIVE VSD.
UNIVENTRICULAR HEART, ACROSS THE
BULBOVENTRICULAR COMMUNICATION.
TOF WITH ABSENT PV.
46. APICAL IMPULSE (COMMONEST IS RV
TYPE APEX)
LV TYPE APEX
• TRICUSPID ATRESIA.
• PULMONARY ATRESIA
WITH INTACT SEPTUM
• UNIVENTRICULAR (LV)
HEART
• EBSTEIN’S ANOMALY
• LSVC TO LEFT ATRIAL
COMMUNICATION.
ABSENT RV
ACTIVITY
• HYPOPLASTIC RIGHT
HEART SYNDROME.
48. HEART SOUNDS - SINGLE S2
ABSENT P2
1. PULMONARY ATRESIA
2. SEVERE PS AND
DYSPLASTIC PULMONARY
VALVE
3. TRUNCUS ARTERIOSUS
4. ABSENT PULMONARY
VALVE.
INAUDIBLE P2
1. D–TGA
2. MPGA.
ABSENT A2
1. AORTIC ATRESIA.
INAUDIBLE A2
1. LOUD P2 IN PULMONARY
AREA (SEVERE PHT.)
SYNCHRONOUS A2 AND P2
1. VSD WITH BIDIRECTIONAL
FLOW
2. SINGLE VENTRICLE.
49. HEART SOUND – S2
FIXED, WIDE : TAPVC, ASD WITH SHUNT REVERSAL.
NORMAL / NARROW / SINGLE : PDA WITH SHUNT REVERSAL.
SINGLE LOUD S2 (A2) : ANY ENTITY IN TETRALOGY
PHYSIOLOGY WITH SEVERE PS, CCHD WITH MALPOSED GREAT
ARTERIES.
SINGLE LOUD S2 (P2) : VSD WITH SHUNT REVERSAL.
WHEN CYANOSIS IS MILD AND GREAT ARTERIES ARE
NORMALLY RELATED, P2, THOUGHT SOFT, MAY BE
PRESERVED IN TETRALOGY PHYSIOLOGY.
A PRESERVED P2, WHATEVER MAY BE THE DEGREE
OF CYANOSIS, EXCLUDES TRUNCUS ARTERIOSUS,
PULMONARY ATRESIA AND TOF WITH ABSENT PULMONARY
VALVE.
50. HEART SOUNDS – S3/S4
MULTIPLE HEART SOUNDS : EBSTEIN’S
ANOMALY.
S4 : PS WITH STRETCHED PFO, ASD/ EP.
S4 (LV) : CORRESPONDS THE RIGHT
ATRIAL A WAVE AND DENOTING A
NONRESTRICTIVE ASD IN TRICUSPID
ATRESIA.
51. EJECTION CLICK
PULMONARY CLICK : EISENMENGER
PHYSIOLOGY.
AORTIC CLICK : MORE SEVERE THE
PULMONARY STENOSIS, MORE IS THE
PROBABILITY OF GETTING IT IN TETRALOGY
PHYSIOLOGY.
VERY PROMIENT, HIGH PITCHED : TRUNCUS
ARTERIOSUS.
52. MURMUR
SYSTOLIC MURMUR
SEVERE THE CYANOSIS, LESSER IS THE GRADE
OF THE MURMUR.
EXCEPTION IS THE OBLIGATORY MURMURS
IN DORV/ VSD/ PS, TRICUSPID ATRESIA/ VSD
(MORE SO WHEN VSD IS RESTRICTIVE) AND IN
UNIVENTRICULAR HEART (BULBOVENTRICULAR
FLOW).
53. DIASTOLIC MURMUR
TRUNCUL REGURGITION.
TOF WITH ABSENT PULMONARY
VALVE.
TOF WITH AORTIC REGURGITION.
GRAHAM STEEL MURMUR IN
EISENMENGER PHYSIOLOGY.
54. DD OF A CONTINOUS MURMUR
WITH OR WITHOUT CYANOSIS ?
CONTINOUS OR A TO & FRO
MURMUR ?
55. CONTINOUS MURMURS WITHOUT CYANOSIS
PDA
AP WINDOW
VENOUS HUM
CORONARY AV
FISTULA
ALCAPA
RSOV
• PERIPH PULM.
STENOSIS
• SYSTEMIC AV FISTULA
• COLLATERALS IN COA
• MAMMARY SOUFFLE
• AORTICO-LV TUNNEL
56. CONTINOUS MURMUR WITH CYANOSIS
DUCT IN TETRALOGY
PULM ATRESIA WITH DUCT
MAPCAS IN PULM ATRESIA
SUPRACARD. TAPVR
PULM AV FISTULAE
POST BT SHUNT (THOMAS-BLALOCK-TAUSSIG SHUNT)
POST - POTT’S, WATERSTON, CENTRAL SHUNTS
58. TO & FRO MURMUR
WITHOUT CYANOSIS WITH CYANOSIS
VSD AR
MR AR
AS AR
PS PR
POST OP
TETRALOGY
MR AR
TR PR ETC
• TETRALOGY WITH AR
• TRUNCUS WITH
REGURG
• ABSENT PV SYNDROME
61. CCHD - ↓ PBF
- INSPECTION /PALPATORY FINDINGS
CYANOSIS & CLUBBING
POLYCYTHEMIA
QUIET PRECORDIUM TO INSPECTION
& PALPATION
NO HARRISONS SULCUS (OR)
PRECORDIAL BULGE
APEX WELL WITHIN LIMITS IF VISIBLE
NO PALPABLE SOUNDS (OR) THRILLS
62. CCHD WITH ↓ PB FLOW
AUSCULTATORY FINDINGS
NORMAL FIRST HEART SOUND
SINGLE SECOND HEART SOUND
PULM COMPONENT INAUDIBLE
STENOTIC PULMONARY MURMUR
SLIGHTLY AFTER S1
STOPS SHORT OF S2
OTHER MURMURS – DUCTAL/ MAPCA/ AR
63. Tetralogy of Fallot (TOF)
TOF
TOF: Cyanosis
: Cyanosis
proportional to RVOT
proportional to RVOT
obstruction
obstruction
RV apex, parasternal
RV apex, parasternal
heave ,
heave , Single S2,
Single S2, Ejection
Ejection
systolic murmur at Left
systolic murmur at Left
upper sternal edge
upper sternal edge
TOF with PA
TOF with PA: Single S2
: Single S2
but soft murmur
but soft murmur
sometimes
sometimes continuous
continuous
from the MAPCAS
from the MAPCAS.
.
Occasionally CCF
Occasionally CCF
64. EJECTION MURMUR IN FALLOT
PHYSIOLOGY
LENGTH & LOUDNESS INVERSELY
PROPORTIONAL TO SEVERITY OF STENOSIS
IN ISOLATED PVS – THE OPPOSITE
ABSENT MURMUR – ACQUIRED PULM ATRESIA
- MAPCA MURMUR OVER BACK
- SOFT DUCTAL MURMUR
TO & FRO – AORTIC REGURG / ABS PV
SYNDROME
70. CYANOSIS WITH INCREASED FLOW
TRANSPOSITION PHYSIOLOGY
TAPVC
COMMON MIXING LESIONS
WITH UNOBSTRUCTED PULMONARY
FLOW
PA, VSD WITH SEVERAL MAPCAS.
72. CCHD WITH ↑ P B FLOW
INSPECTION FINDINGS
SICKLY UNDERWEIGHT INDIVIDUAL
CYANOSIS & CLUBBING -MILD TO MODERATE
SEVERE PHT, EISENMENGER – MODIFIES FINDINGS
HARRISSON’S SULCUS, PRECORDIAL BULGE
ACTIVE PRECORDIUM, RV, LV, PA PULSATIONS
OBVIOUS CARDIOMEGALY
73. CCHD WITH ↑ P B FLOW
PALPATORY FINDINGS
ACTIVE PRECORDIUM
RV IMPULSE – DORV, TAPVR, TGA VSD PS
LV IMPULSE – SINGLE VENTRICLE, AVSD-AV
REGURG
PALPABLE SECOND SOUND / THRILLS RARE
74. Transposition of the Great Arteries
(TGA)
D-TGA with IVS-
D-TGA with IVS-
cyanosis and tachypnea,
cyanosis and tachypnea,
S2 single and loud
S2 single and loud, soft
, soft
or absent MURMUR.
or absent MURMUR.
D-TGA with VSD-
D-TGA with VSD-
presents with cardiac
presents with cardiac
failure, subtle cyanosis
failure, subtle cyanosis
and holo systolic VSD
and holo systolic VSD
murmur
murmur.
.
79. TRUNCUS ARTERIOSUS
• CLINICAL
CLINICAL
PRESENTATION
PRESENTATION
-in neonates
-in neonates murmur
murmur
and mild cyanosis,
and mild cyanosis,
-later develops
-later develops Cardiac
Cardiac
failure, valve
failure, valve
insufficiency, single S2,
insufficiency, single S2,
Loud ESM with thrill and
Loud ESM with thrill and
MDM due to mitral flow
MDM due to mitral flow
murmur
murmur
81. Ebstein’s Anomaly of TV
Ebstein’s Anomaly of TV
Clinical feautures-
Clinical feautures-
- depends on degree of
- depends on degree of
displacement of
displacement of
Tricuspid Valve
Tricuspid Valve, can be
, can be
mild till teenage or
mild till teenage or
severe with cyanosis in
severe with cyanosis in
neonate.
neonate.
WPW syndrome
WPW syndrome is an
is an
association, multiple
association, multiple
clicks, holo systolic TR
clicks, holo systolic TR
murmur, gallop.
murmur, gallop.
85. ATRIAL SEPTAL DEFECT (ASD)
A.S.D[O.S type]
PRECORDIUM
-hyper dynamic RV apical impulse
-systolic pulsation in 2nd
LICS
AUSCULATION
-fixed splitting of S2
-split S1 [loud T1]
-ESM in pulmonary area
-tricuspid mid-diastolic flow murmur
X-RAY
-pulmonary plethora
-markeoly dilated pulmonary
trunk and its branches
-dilated RA and RV
ECG
-RSR’ in V1
86. Ventricular Septal Defect (VSD)
• Clinical representation
depends on size of VSD
&PVR.
• Moderate sized defect with
low PVR.
-CCF in infancy
-murmur detected at first
well baby examination
-retarded growth &
development
-hyper dynamic LV
-PSM in L+ 2 to 4 ICS with
thrill
-flow MDM across mitral
valve
87. Patent Ductus Arteriosus (PDA)
• HISTORY : Premature birth,
maternal rubella, birth at
high altitude.
• CLINICAL SIGNS:
1.Continuous murmur
-peak around S2
-maximal in 1st
or 2nd
LICS
-contains eddy
sounds[later
systole and early
diastole]
2.LV apical impulse
3.Brisk arterial pulse with
wide pulse pressure
88. Coarctation of the Aorta
• Systemic hypertension
• Abnormal differences in upper
and lower limb pulses and
systolic BP[Radio femoral
delay]
• Prominent carotid and
suprasternal pulsations
• Systolic murmur over posterior
interscpular region, Lt sternal
border and suprasternal notch
• Co-existing BCAV-
AEC,ejection systolic
murmur/EDM in aortic or 2nd
aortic area.
• X-RAY
-3RD
to 8th
posterior
ribs [Rib notching]
-seldom before 6yrs of age
89. COARCTATION OF AORTA
ASYMPTOMATIC ADULTS –
COLLATERALS
HYPERTENSION !
FEMORALS !!
BICUSPID AV IN 80% - EJECTION CLICK !
COLLATERAL MURMUR OVER BACK
91. KEYS TO CLINICAL DIAGNOSIS
WORK IN ORDER
COLOUR - CYANOSIS, PALLOR, POLYCYTHEMIA
EXAMINE THE PATIENT HEAD TO FOOT FOR CONGENITAL DEFECTS
PALPATE ALL PERIPHERAL PULSES & RECORD BOTH UL & LL BP
INSPECT – FOR CHEST FORM, PULSATIONS
PALPATE TO DETERMINE – WHICH VENTRICLE ?
FORGET THE MURMUR !!
LISTEN FIRST TO S1, AND THEN TO S2
CAN YOU SPLIT THE SECOND SOUND ??
THEN CONCENTRATE ON THE COMPONENTS
FINALLY THE MURMURS – SYSTOLIC – EJECTION OR PANSYST.
IS THERE A DIASTOLIC MURMUR (OR) CONTINOUS MURMUR
92. CONCLUSION
-
-INTELLIGENT SELCTION OF INVESTIGATIVE
-
PROCEDURES FROM AN EVER - INCREASING ARRAY
-
REQUIRES FAR MORE SOPHISTICATED DECISION
-
MAKING.
-THE BASIC CLINICAL ASSESSMENT PROVIDES THE
INFROMATION NECESSARY FOR MOST OF THESE
DECISIONS.
-WITH INCREASING EMPHASIS ON THE COST OF MEDICAL
CARE, A RESURGENCE OF INTEREST IN THE
INEXPENSIVE AND SAFE CLINICAL EXAMINATION IS
LIKELY.
