3. 2. Is it Congenital or Acquired ?
Congenital
Symptoms from infancy
Feeding difficulties FTT
Recurrent hospital admissions
Acquired
Rheumatic fever:
Fever, joint pain, chorea
4. 3. If it is congenital, is it cyanotic or
acyanotic?
Why cyanosis occurs?
What are the types of
cyanosis?
Which one is present in
cyanotic CHDs?
How to differentiate?
5.
6. 4. If it is Cyanotic CHD, what is the actual
CHD ?
PBF
TOF
Tricuspid
Atresia
TGA
Single
ventricle with
PS
PBF
Truncus arteriosus
TAPVC
Single ventricle
without PS
Cyanotic CHD
BASED ON MURMURS, CHANGE IN HEART SOUNDS
INVESTIGATIONS
7. 5. If it is Acyanotic CHD, what is the actual
CHD ?
ASD
VSD
PDA
PS
AS
CoA
Volume overload (Shunt) Pressure overload (Obstn.)
BASED ON MURMURS, CHANGE IN HEART SOUNDS
INVESTIGATIONS
ACYANOTIC CHD
8. 6. Is it Rheumatic Fever or
RHD?
If so, which valves are involved?
Is there any evidence of pericarditis or
myocarditis?
9. 7. Are there any complications?
CCF
Infective Endocarditis
Pulmonary Hypertension
10. NADA’s Criteria
Major :
Systolic murmur Gr.
III or more in
intensity.
Diastolic murmur
Cyanosis
CHF
Minor:
Systolic murmur Gr.
II or less in intensity.
Abnormal 2nd sound
Abnormal ECG
Abnormal CXR
Abnormal BP
Presence of 1 major or 2 minor criteria suggest
presence of Heart Disease
11. Perinatal History
Was the mother immunized against rubella
prior to delivery?
Was the mother scanned in antenatal period?
H/o fever with rash in 1st trimester, painful
swelling behind the ear.
15. Family History
Consanguinity
Maternal age at conception
Age of the father
Heart disease in family
Hereditary diseases
PS common in Noonan syndrome
Rheumatic fever
Diabetic mother
20. Palpation
Apex beat
Parasternal Heave
Thrills
Any palpable pulsations in precordial region
Percussion
Auscultation
21. Pulse
A pulse is a waveform that is felt by the finger,
produced during cardiac systole which travels
along the arterial tree, at a rate much faster
than that of blood column.
22. Assessment of pulse
Rate
Rhythm
Volume
Character
Pulse deficit
Condition of vessel wall
R-F delay
Symmetry
23.
24. Pulse rate :
Counted for full 1 minute by palpating the radial
artery
36. When the fall in BP is more than 10 mmHg
during inspiration, it is Pulsus paradoxus.
37. Pulse Deficit:
Difference between HR & PR when counted
simultaneously for 1 min.
Causes : Atrial fibrillation and VPCs
Radio-radial delay:
Seen in : Pre Subclavian coarctation, supravalvular
AS
Radio-femoral delay:
Seen in : CoA, Aortic embolism
39. Width:
40% of circumference
Length:
80-100 % of
circumference
40. JVP
Expressed as vertical height from the sternal
angle to the zone of transition of distended and
collapsed JVP.
The patient is kept at 45 degree.
The upper level of pulsations in the IJV is
seen.
41.
42. JVP – indicator of Rt. Atrial pressure
Centre of RA is approx 5 cm from sternal
angle.
Right Atrial Pressure = Vertical ht. Of blood
column + 5 cms (cm of
H20)
Normal JVP = < 8 cms of H2O or < 6mmHg
48. Palpations
General rule :
Fingertips : to feel
pulsations,
Base of fingers :
Thrills,
Base of hand ( or
ulnar aspect ) :
Heaves
49. Apical Impulse :
It refers to the lowermost and outermost point of definite
cardiac impulse, which gives maximum thrust to the
palpating finger.
Normal variation in location of apical impulse with
age
Age Position of apical
impulse
Relation to midclavicular
line
Infancy Left 4th ICS Lateral to mid clavicular line
Approx 5 years Left 5th ICS In the Midclavicular line
Older children Left 5th ICS Medial to midclavicular line
50.
51.
52. Parasternal Heave :
A palpable thrust, which lifts the palpating hand.
Seen in RVH and Left atrial enlargement.
Palpated by ulnar aspect of hand.
Grading :
I. Instant lift, visible not palpable
II. Visible and palpable, lift can be obliterated
III. Visible and palpable, lift cant be obliterated
53. Thrills :
These are palpable vibrations of murmurs which
accompany any organic murmur of grade 3 or
more.
54. Percussion
It is done basically to see enlargement of
dullness of the cardiac region.
Cardiac causes : Cardiomegaly, pericardial
effusion
56. Heart sounds:
Relative, brief auditory vibrations of variable
intensity, frequency & quality, produced by closure
of heart valves.
57. S1 Abnormalities
Soft S1 Loud S1 Split Reverse
split
MR MS RBBB RVP
TR TS LVP Ectopic beats
Calcification
of AV valves
High output
states
Pulm.
Hypertension
58. S2 Abnormalities
Soft S2 Loud S2 Single S2
Loud A2 Loud P2 Absent A2 Absent P2
AS Syst. Htn Pulm. Htn AS PS
PS Aortic
aneurysm
ASD, PDA TOF
Calcified lesions of
semilunar valves
Dilated
aorta
LargeVSD TGA
59. Splitting of S2
Wide- Fixed Wide-
Variable
Narrow Reverse-split
Early A2/Late P2 VSD Severe
AS
Late A2/Early P2
MR LVP Severe
PS
Aortic stenosis
ASD, RBBB HOCM
61. Causes of S3
Physiological S3 Pathological S3
Children High output states
Young adults CHD – ASD, VSD, PDA
MR, TR, AR
62. Opening Snap
Due to opening of AV valves
Can be heard at the apex :
MS, MR
VSD
PDA
Or can be heard at parasternal region :
Tricuspid stenosis
Tricuspid regurgitation
ASD
63. Ejection Click :
It is a sharp, clicking sound arising from the
cardiac valves due to sudden swelling of the
pulmonary artery, abrupt dilatation of aorta or
forceful opening of the aortic cusps.
Early ejection systolic click is seen in aortic and
pulmonary valve stenosis
Midsystolic ejection click is seen in floppy mitral
valve.
64. Pericardial Rub :
Due to sliding of 2 inflamed layers of pericardium
Scratching, grating in character
Triphasic : during misdystole, mid diastole & pre
systole)
Best heard along left sternal edge in 3rd & 4th ICS
65. MURMURS :
Occur due to the turbulence caused by either an
increased flow through a normal/stenosed valve
or a normal flow through a stenosed valve/orifice
Auscultation should be done over precordium,
back and over carotids
66. They should be described in the following way
Pitch
Timing & character
Systolic/diastolic
Area where best heard
Intensity
Whether best heard with bell or diaphragm
Conduction
Variation with respiration
Posture in which best heard
Variation with dynamic auscultation.
67. Eg/: murmur of MS is best described as;-
Low-pitched,
Mid-diastolic,
Rumbling murmur,
Best heard in Apical region,
in LL position
with the bell of stethoscope,
not radiated,
increases with isometric exercise.
68. Systolic murmur
grading
I. Very soft (heard in
quite room)
II. Soft, but easily
audible
III. Moderate, no thrill
IV. Loud with thrill
V. Very loud with thrill,
heard with steth
barely placed on
chest
VI. Loud and audible with
stethoscope just off
the chest wall
Diastolic murmur
grading
I. Very soft
II. Soft
III. Loud
IV. Loud with thrill
77. Named Murmurs:
Carey-coomb’s :
Short, Middiastolic
Best heard at apex
MS in acute RHD
Graham-steele :
High pitched, early diastolic
Best heard at left sternal border, 2nd ICS
During expiration in PR
78. Gibson’s :
Continuous machinery murmur of PDA
Cole-cecil :
Murmur of AR, heard well in axilla.
Austin flint:
Low pitched rumbling mid diastolic murmur
Best heard at apex in severe AR
79. Gallavardin phenomenan :
The harsh noisy component of ESM of AS.
Best heard at the right sternal border and radiated to
neck
Carvallo’s sign :
Pansystolic murmur of TR, best heard in tricuspid
area.
Becomes louder during inspiration
80. Innocent murmurs:
Functional/ benign murmurs
Absence of anatomical/functional abnormalities of
heart and circulation
Accentuated during periods of febrile illness and
high output states
Characteristic features :
Asymptomatic
Normal cardiac silhouette on chest-xray
81. Usually systolic
Less than grade 3
No cyanosis
Normal pulses
Normal heart sounds
82. Dynamic auscultation
During dynamic auscultation, as opposed to
conventional auscultation, the patient is asked
to change position or perform certain activities
that enable the physician to hear the murmurs
and heart sounds.
83. Respiration
Valsalva manouvre
Muller manouvere
Standing to squatting
Squatting to standing
Passive leg exercise
Isometric hand grip
Leaning forward
Chin turned upwards
84. Respiration :
During inspiration:
Right sided murmur become louder
Left sided murmurs become softer or unchained
Expiration has the opposite effect
85. Valsalva manouvre:
It is an attempted forced expiration in closed
glottis, when both the mouth and nose are closed.
It increases the intrathoracic pressure
Murmur of MVP becomes louder
Systolic murmur of HOCM become louder
ESM of AS will be decreases
86. Standing to squatting:
It increases blood return and systemic vascular
resistance.
HOCM becomes soft due to increased diastolic
volume.
Isometric hand grip:
Increases systemic circulation
Murmurs of regurgitation ( MR,VSD) become louder
due to back pressure
Murmurs of AS become softer due to decreased
gradient across the valve.
