This document provides guidance on evaluating a child with congenital heart disease. It outlines key questions to answer, including whether the condition is cyanotic or acyanotic. A thorough history is important, including prenatal, natal, and postnatal details. A physical exam involves assessing vital signs, growth, precordial examination, palpation of pulses and thrills, and auscultation of heart sounds and murmurs. The goal is to characterize the nature and severity of the congenital heart condition.
This presentation is a simplified version of the various types of cardiac arrythmias seen in pediatric age groups. We have discussed supraventricular tachycarsias and prolonged QT syndrome in details here. Hope everyone finds it useful.
Definition, classification, epidemiology, etiology, diagnosis, prognosis of DCM, HOCM, LVNC
Also review of acute myocarditis in children
R/v of heart failure management
This presentation is a simplified version of the various types of cardiac arrythmias seen in pediatric age groups. We have discussed supraventricular tachycarsias and prolonged QT syndrome in details here. Hope everyone finds it useful.
Definition, classification, epidemiology, etiology, diagnosis, prognosis of DCM, HOCM, LVNC
Also review of acute myocarditis in children
R/v of heart failure management
This presentation is an overview of congenital cyanotic heart diseases, with a special discussion on Tetralogy of Fallot. We discuss the pathophysiology, clinical manifestations as well as the most updated management options for treating this condition. The topic ends with a few important complications seen in TOF patients. Hope you find it useful.
You can follow us on: Facebook page 'Neonatohub' (online academic platform) OR visit our YouTube channel 'Neonatohub' for more paediatric and neonatology presentations.
Approach to cardiac murmurs and cardiac examination in childrenVarsha Shah
Cardiovascular examination in children for MBBS undergraduate, Residents, Trainees, pediatricians, GP, family physicians, nursing , dental, allied health students
a not-for profit/sale presentation for educational purposes only.
Design heavily influenced and inspired by Jesse Desjardins. Thank you to Jesse Desjardins.
Congenital heart disease is one or more problems with the heart's structure that exist since birth. Congenital means that you're born with the defect. Congenital heart disease, also called congenital heart defect, can change the way blood flows through your heart. IF YOU LIKE GIVE YOUR LIKES AND FOLLOW THIS LINK
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
The prostate is an exocrine gland of the male mammalian reproductive system
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Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Approach to child with congenital heart disease
1. APPROACH TO CHILD
WITH CONGENITAL
HEART DISEASE
PRESENTOR : DR ANKUR PURI
MODERATOR : DR DEVENDER BARUA
2. 5 Basic questions to be answered in
every case
1) Cyanotic or Acyanotic?
2) Increased Pulmonary Blood Flow /
Decreased PBF ?
3) Origin of the lesion is in the Right /Left
heart?
4) Which is the dominant ventricle?
5) Presence/ absence of Pulmonary
Hypertension?
3. HISTORY TAKING:
As in the evaluation of any other system,
history taking is a basic step in cardiac
evaluation. Maternal history during pregnancy
is often helpful in the diagnosis of congenital
heart disease (CHD) because certain prenatal
events are known to be teratogenic.
Age of Presentation-
• PDA before 6 wks,
• VSD after 6 wks,
• ASD 1year
4. CONT…
ANTE-NATAL HISTORY:
H/o infections, disease & drugs in the mother.
-- Infections :
• Maternal Rubella during the first trimester causes PDA/
PS.CMV, HSV and
• Coxsackie-B during later trimesters may cause Neonatal
Myocarditis.
-- Maternal Disease :
• Diabetes Mellitus - TGA/Cardiomyopathy.
• SLE/mixed connective tissue disease - Complete Heart Block
5. CONT…
-- Drugs/Medications:
• Lithium – Ebstein’s anomaly.
• Valproic Acid - VSD, AS, Pulmonary Atresia with intact
ventricular septum & COA.
• Phenytoin – PS, AS, COA & PDA
• Other medications suspected of causing CHD include
progesterone and estrogen (VSD, TOF, TGA)
• Excessive alcohol intake during pregnancy has been
associated with VSD, PDA, ASD, & TOF (fetal alcohol
syndrome).
6. CONT…
NATAL HISTORY:
• Birth Weight:
• If infant is SGA, this may indicate Intra-uterine infections or use of
chemicals or drugs ( e.g Rubella syndrome & fetal alcohol
syndrome)
• If infant is LGA – often seen in Diabetic Mother - TGA
7. CONT...
POST NATAL HISTORY:
• H/o poor weight gain / Failure to thrive in infants with CCF or
severe cyanosis ( weight more affected than height).
• H/o Poor feeding (i.e. suck-rest-suck cycle) due to fatigue
and dyspnoea.
• H/o Cyanosis, “Cyanotic spells,” & Squatting
• H/o tachypnoea, dyspnoea & puffy eyelids are signs of CHF.
Left
heart failure produces tachypnea with or without dyspnea.
Tachypnea becomes worse with feeding and eventually
results in
poor feeding and poor weight gain.
8. CONT...
H/o frequent respiratory tract infections (due to Left to Right
shunt with increased PBF predispose to LRTI). Frequent
upper respiratory tract infections are not related to CHD.
H/o decreased exercise tolerance (seen with Left to right
shunts, cyanotic lesions, valvular stenosis or regurgitation
and arrhythmias) -- Ask in terms of inability to climb
stairs/walk short distances/play outdoor games as compared
to other children of the same age.
9. HISTORY OF MODES OF
PRESENTATION:
H/o Murmur :
• Time of detection – In neonatal age(with in few hours of
birth): AS/PS/Small VSD/PDA. In Early infancy:
Large
VSD/PDA(after 6 - 8 weeks i.e. regression of the
PVR)
• If incidentally found during fever/pre-school evaluation
– innocent murmur.
• Most common conditions which may present as
10. CONT...
H/o Cyanosis :
o Presenting in the first week of life – (all ‘T’):
-TGA
-Truncus Arteriosus
-Total AV-Canal Defect
-Total Pulmonary Atresia
-Tricuspid Atresia
-Tricuspid Regurgitation with Ebstein’s anomaly of the
-Tricuspid Valve.
o After first week of life –
- Tetralogy of Fallot’s,
- Total Anomalous
- Pulmonary Venous Circulation.
11. CONT...
H/o Cardiac Failure:
o First week of life – CoA,
Critical Aortic Stenosis
Truncus Arteriosus
Hypoplastic Left Heart Syndrome.
o 1 – 4 weeks – PDA
VSD with coarctation
Severe coarctation
Transposition with large VSD or PDA
o 1 – 2 months – VSD, PDA, TAPVC
o 2 – 6 months – VSD, PDA, ALCAPA,
Endocardial cushion defcts
13. CONT...
H/o Cyanotic Spells:
o Classical: TOF with infundibular spasm.
o Ask about –
--Time of occurrence – common in early morning/ on
awakening / post feeds.
--Duration and Frequency of the spells – for prognosis and
early intervention.
--H/o squatting episodes /knee-chest positions by self.
o Breathing rapidly/ no breathing during the spell – to
differentiate from Breath holding spells.
14. CONT...
H/o Cerebral events viz
Convulsions/Transient Ischemic Attacks/Strokes:
-Emboli may occur with right to left shunts,
-Polycythemia may lead to cerebral thrombosis and
brain
abcess.
15. FAMILY HISTORY:
H/o Hereditary Disease –
- PS secondary to a dysplastic pulmonary valve is common in
Noonan's syndrome.
- Lentiginous skin lesion (l entigines, e lectrocardiogram
abnormalities,
ocular hypertelorism, p ulmonary stenosis, a bnormal
genitalia,
r etardation of growth, and d eafness [LEOPARD]
syndrome) is
often associated with PS and cardiomyopathy.
16. FAMILY HISTORY:
H/o Congenital Heart Disease in parents/siblings
(risk of recurrence) –
- When one child is affected, the risk of recurrence in siblings
is about 3%.
- Lesions with a higher prevalence (e.g., VSD) tend to have a
higher
risk of recurrence, & lesionsn with a lower prevalence
(e.g. tricuspid atresia, persistent truncus arteriosus) have
a
lower risk of recurrence.
17. EXAMINATION
As with the examination of any child, the order and
extent of
the physical examination of infants and children with
potential
cardiac problems should be individualized.
Supine is the preferred position for examining patients in
any age
18. CONT…
Growth pattern
- Growth impairment is frequently observed in infants
with
congenital heart diseases (CHDs).
- Different patterns of growth impairment are seen in
different
types of CHD.
a) Cyanotic patients have disturbances in both height
and weight.
b) Acyanotic patients, particularly those with a large
left-to-right shunt, tend to have more problems
with weight gain than with linear growth.
20. Temperature
o Fever, chills and rigors
IE
RF
Pericarditis, myocarditis
o Hypothermia is seen in cardiogenic failure or shock
21. Respiration
o Rate, rhythm, Type
o Breathing: dyspnea + wheezing (asthma, COPD,
LV
failure).
o Breathing: Chyne-Stokes breathing (stroke, CHF,
sedation,
uremia).
22. Pulse
o Rate
o Rhythm
o Character
o Volume
o Radio – radial delay
o Radio femoral delay
o Palpable Peripheral pulse
o Jugular venous pressure
23. Pulse
The normal pulse rate varies with the
patient's age and status. The younger the
patient, the faster the pulse rate.
24. Pulse
Normal Heart Rate for Different Ages
Age Rate Average
Newborn 100 – 180 140
1 – 11 months 80 – 160 120
2 – 3 years 80 – 130 110
4 – 5 years 80 – 120 100
6 – 8 years 75 – 115 95
> 8 years 70 – 110 90
25. CONT…
Every patient should have palpable pedal pulses, either
dorsalis pedis, tibialis posterior, or both. It is often easier
to feel pedal pulses than femoral pulses.
If a good pedal pulse is felt, coarctation of the aorta
(COA) is effectively ruled out, especially if the blood
pressure in the arm is normal.
26. CONT…
o Normally femorals felt just before radial
o Radio – radial – pre subclavian COA
If the right brachial pulse > left brachial pulse,
COA
occurring near the origin of the left subclavian
artery
or supravalvular aortic stenosis (AS)
o Radio femoral – post subclavian COA
A weaker right brachial pulse than the left
suggests and aberrant right subclavian artery
27. CONT…
Bounding pulses are found in aortic run-off
lesions such as PDA, aortic regurgitation
(AR), large systemic arteriovenous fistula,
or persistent truncus arteriosus (rarely).
Pulses are bounding in premature infants
because of the lack of subcutaneous
tissue and because many have PDA.
28. Blood Pressure
o Blood pressure should be measured in the legs as
well as in the arms.
o In older children, a mercury sphygmomanometer
with a cuff that covers approximately two-thirds of
the upper part of the arm or leg.
o A cuff that is too small results in falsely high
readings, whereas a cuff that is too large records
slightly decreased pressure.
o The pressure recorded in the legs with the cuff
technique is approximately 10 mm Hg higher than
that in the arms
29. CONT…
o Blood pressure varies with the age of the child and
is closely related to height and weight.
o Exercise, excitement, coughing, crying, and
struggling may raise the systolic pressure of infants
and children as much as 40-50 mm Hg greater than
their usual levels
31. CONT…
Obese child
Pericardial effusion
Severe cardio
myopathy
Thin patient,
Volume over load,
Lt to Rt shunt ( PDA,
VSD)
Silent Precordium
Hyper dynamic
Precordium :
Inspection
A precordial bulge to the left of the sternum with increased
precordial activity suggests cardiac enlargement; such bulges can
often best be appreciated by having the child lay supine with the
examiner looking up from the child’s feet
Parasternal Lift – Severe
MR
32. CONT…
Harrison's groove, a line of depression in the bottom of
the rib cage along the attachment of the diaphragm,
indicates poor lung compliance of long duration, such as
that seen in large left-to-right shunt lesions.
33. CONT…
Inspection
APICAL IMPULSE
o Lowest and outer most point of
cardiac pulsation
o The apical impulse is normally
at the 5th ICS in the MCL after age 7.
o Before this age, the apical impulse
is in the 4th ICS just to the lateral to the MCL.
o Shifting :
o Lateral & inferior – LVH
o Only lateral – RVH
34. CONT…
Palpation
Confirm the position of apex beat
Preschool – 4th ICS just lateral to MCL
Older child – 5th ICS
Character of apex beat
Tapping - MS
Heaving – force full, well sustained - LVH, pressure
over load - AS
Hyper dynamic – ill sustained - Volume over load -
MR
Para sternal heave
Right ventricular enlargement – ASD, VSD
Left atrial enlargement – MS, MR
35. CONT…
Palpation
Thrills
Thrills are the palpable equivalent of murmurs and correlate
with
the area of maximal auscultatory intensity of the murmur.
1. Thrills in the upper left sternal border originate from the
pulmonary valve or pulmonary artery (PA) and therefore
are
present in PS, PA stenosis, or PDA (rarely).
2. Thrills in the upper right sternal border are usually of aortic
origin
and are seen in AS.
3. Thrills in the lower left sternal border are characteristic of a
36. CONT…
Palpation
Thrills
5. The presence of a thrill over the carotid artery or arteries
accompanied by a thrill in the suprasternal notch suggests
diseases of the aorta or aortic valve (e.g., COA, AS). An
isolated thrill in one of the Carotid arteries without a thrill in
the suprasternal notch may be a carotid bruit.
6. Thrills in the intercostal spaces are found in older children
with severe COA and extensive intercostal collaterals.
38. CONT…
Auscultation
Use the diaphragm for high pitched sounds and
murmurs
Use the bell for low pitched sounds and murmurs.
The entire precordium, as well as the sides and back of
the
chest, should be explored with the stethoscope.
Systematic
attention should be given to the following aspects:
a) Heart rate and regularity
b) Heart sounds
c) Systolic and diastolic sounds
39. CONT…
Auscultation
Heart sounds
Intensity and quality of the heart sounds, especially the second
heart sound (S2), should be evaluated.
Abnormalities of the first heart sound (S1) and the third heart sound
(S3) and the presence of a gallop rhythm or the fourth sound (S4)
should be noted. Muffled heart sounds should also be noted.
1st Heart sound(S1) – closure of mitral & tricuspid valve. Best heard
at the apex or lower left sternal border.
2nd Heart sound (S2) - The S2 in the upper left sternal border (i.e.,
pulmonary valve area) is of critical importance in pediatric
cardiology
41. CONT…
Auscultation
Heart sounds
The S2 must be evaluated in terms of the degree of splitting
and the intensity of the pulmonary closure component of the
second heart sound (P2) in relation to the intensity of the
aortic closure component of the 2nd heart sound (A2).
Physiological split –
Normal splitting between
A2 & P2 which varies with
inspiration and expiration
44. Spliting of Second Heart Sound
Expiration InspirationSpliting
Normal
Wide & Variable
Paradoxical
Wide & Fixed
Single Second Sound
MR, VSD, PS
ASD, TAPVC,
RBBB,MR
AS, PDA, AR
TOF,TGA,severe
AS
45. Abnormal heart sounds –
Contd..
o 3rd heart sound – due to maximal ventricular
filling
S3 Gallop – Myocarditis, CCF
o 4th heart sound – due to rapid emptying of
atrium
Occurs in constrictive pericarditis, hypertrophic
cardiomyopathy (HCM)
46. Additional Sounds
o Click – arise due to semi lunar valves
o Ejection systolic clicks(EC) – AS, PS
o Opening snap(OS) – due to abnormal mitral & tricuspid
leaflets -- Occurs in ASD, VSD, RHD – MS / TS
o Mid systolic Click(MC) – MVPS
o Multiple Clicks – Ebstein’s Anomaly
47. CONT…
Auscultation
MURMURS
o Caused by normal flow through a abnormal
valve or abnormal flow through a normal
valve
o Each heart murmur must be analyzed in
terms of
intensity (grade 1 to 6)
timing (systolic or diastolic)
location
transmission
48. CONT…
Auscultation
MURMURS- Intensity
Intensity of the murmur is customarily graded from 1 to 6.
Grade 1 Barely audible
Grade 2 Soft, but easily audible
Grade 3 Moderately loud, but not accompanied by a thrill
Grade 4 Louder and associated with a thrill
Grade 5 Audible with the stethoscope barely on the
chest
Grade 6 Audible with the stethoscope off the chest
51. CONT…
Auscultation
Midsystolic (or Ejection Systolic) Murmurs
Begins after S1 and ends before S2
Midsystolic murmurs coincide with turbulent flow through
the
semilunar valves and occur in the following settings:
(1) flow of blood through stenotic or deformed semilunar
valves (such as AS or PS).
(2) accelerated systolic flow through normal semilunar
valves,
such as seen during pregnancy, fever, anemia, or
thyrotoxicosis
52. CONT…
Auscultation
Cont…
(3) innocent (normal) midsystolic murmurs.
o The intensity of the murmur increases toward the middle and
then decreases during systole (crescendo-decrescendo or
diamond shaped in contour).
o The murmur may be short or long and is audible at the
second left or second right intercostal space.
53. CONT…
Auscultation
Holosystolic Murmurs
o Holosystolic murmurs begin with S1 and occupy all of
systole up to the S2. No gap exists between the S1and
the onset of the murmur.
o Holosystolic murmurs are caused by the flow of blood
from a chamber that is at a higher pressure throughout
systole than the receiving chamber, and they usually
occur while the semilunar valves are still closed
54. CONT…
Auscultation
Cont…
o These murmurs are associated with only the following three
conditions: VSD, MR, and tricuspid regurgitation (TR).
o None of these ordinarily occurs at the base (i.e., second left
or right intercostal space).
55. CONT…
Auscultation
Early Systolic Murmurs
o Early systolic murmurs (or short regurgitant murmurs) begin
with the S1, diminish in decrescendo, and end well before the
S2, generally at or before midsystole.
o VSD, MR, and TR
56. CONT…
Auscultation
Late Systolic Murmurs
o The term “late systolic” applies when a murmur begins in
middle to late systole and proceeds up to the S2
o The late systolic murmur of mitral valve prolapse is
prototypical
57. CONT…
Auscultation
MURMURS-Location
The following four locations are important:
(1) upper left sternal border (pulmonary valve area)
(2) upper right sternal border (aortic valve area)
(3) lower left sternal border
(4) the apex.
58. CONT…
Auscultation
MURMURS-Location
Differential Diagnosis of Systolic Murmurs at the Upper Left
Sternal Border (Pulmonary Area) – mainly a mid systolic
murmur
o Pulmonary Valve stenosis
o ASD
o AS
o Pulmonary flow murmur of newborn
o TOF
o COA
o PDA
59. CONT…
Auscultation
MURMURS-Location
Differential Diagnosis of Systolic Murmurs at Upper Right
Sternal Border (Aortic Area) – mostly midsystolic murmur
o Aortic Stenosis
o Subvalvular AS
Differential Diagnosis of Systolic Murmurs at the Lower
Left Sternal Border – may be holosystolic, early, or
midsystolic type.
o VSD
o ECD
o Vibratory innocent murmur
o TR
60. CONT…
Auscultation
MURMURS-Location
Differential Diagnosis of Systolic Murmurs at the Apex –
holosystolic, midsystolic, or late systolic murmurs.
o MR ( holosystolic )
o MVP (late systolic usually preceeded by a midsystolic click )
o HOCM ( midsystolic )
62. CONT…
Auscultation
MURMURS-Location
For example,
o A holosystolic murmur heard maximally at the lower left sternal
border is characteristic of a VSD.
o A midsystolic murmur maximally audible at the second left
intercostal
pace is usually pulmonary in origin. The location of the
heart
murmur often helps differentiate between a midsystolic
murmur
and a holosystolic murmur.
For example,
o A long PS murmur may sound like the holosystolic murmur of a
VSD; however, because the maximal intensity is at the
upper left
63. CONT…
Auscultation
MURMURS-Transmission
o The transmission of systolic murmurs from the site of
maximal intensity may help determine the murmur's
origin.
o For example, an apical systolic murmur that transmits
well to the left axilla and lower back is characteristic of
MR.
o whereas one that radiates to the upper right sternal
border and the neck is more likely to originate in the
aortic valve.
o A systolic ejection murmur at the base that transmits well
to the neck is more likely to be aortic in origin.
64. CONT…
Auscultation
MURMURS-Quality
o The quality of a murmur may help diagnose heart
disease.
o Systolic murmurs of MR or of a VSD have a uniform,
high-pitched quality, often described as blowing.
o Midsystolic murmurs of AS or PS have a rough, grating
quality.
o A common innocent murmur in children, which is best
audible between the lower left sternal border and apex,
has a characteristic “vibratory” or humming quality
65. When to call a Murmur as Innocent or
functional
Blood Pressure normal
No Cardiomegaly
No cyanosis
Second sound is normal
X Ray chest is normal
ECG is normal
66. Acyanotic Patients with continuous
murmur
PDA
Coronary arteriovenous fistula
Systemic arteriovenous fistula
Coarctation of the Aorta
Peripheral Pulmonic stenosis
Anomalous Left Coronary Artery From Pulmonary Artery
( ALCAPA )
67. Continuous Murmur in cyanotic Patient
Bronchial collaterals in Anomalies of Fallots Physiology
Patent Ductus arteriosus in patients with Fallot’s
physiology
Total anomalous pulmonary venous connection
Pulmonary arterovenous fistula
Surgically created shunts
69. Acyanotic Heart
Increased PBF Normal PBF
LVH or BVH RVH
•VSD
•PDA
•ECD
•ASD(often
RBBB)
•PAPVR
LVH RVH
•AS or AR
•COA
•Primary
myocardial
disease
•MR
•PS
•COA(
in
Infants)
•MS
70. Cyanotic Defects
Increased PBF
LVH or BVH
•Persistent
truncus
Arteriosus
•Single
ventricle
•TGA + VSD
RVH
•TGA
•TAPVR
•HLHS
Decreased PBF
•TGA + PS
•Persistent
truncus
arteriosus
with
hypoplastic
PA
•Single
ventricle
with PS
•Tricuspid
Atresia
•Pulmonar
y atresia
with
hypoplasti
c RV
RVHLVHBVH
•TOF
•Ebstei
n’s
anomal
y (
RBBB)
71. Conditions with Pulmonary
Hypertension :
ASD
VSD
PDA with Eisenmenger’s Complex (reversal of
shunt from Right to Left) ,
Hypoplastic Left Heart Syndrome,
TAPVC with increased Pulmonary Vascular
Resistance.
72. Approach to Congenital Heart
Disease
When to suspected heart disease in children ?
Symptoms of heart disease in children
How to decide whether congenital or acquired ?
Age of onset of symptoms and time of diagnosis
Markers of congenital heart disease
History of acquired heart disease
74. NADA’S Criteria
Systolic murmur
with thrill
Any diastolic
murmur
Cyanosis
Congestive cardiac
failure
Systolic murmur
without thrill
Abnormal P2
Abnormal BP
Abnormal CXR
Abnormal ECG
MAJOR MINOR
1 Major or 2 Minor criteria indicates Presence of
Congenital Heart Disease
75. Approach to Heart disease
Cyanotic CHDAcyanotic CHD
Patient Apply NADAS’
Criteria
Heart Disease
Present
Heart Disease
Absent
Re-evaluate
after Six months
-L to R shunt
-Obstructive
Lesions
-Regurgitant
Lesions
76. Acyanotic Heart Disease
Classificatio
n
Left to Right
Shunts
Obstructive
Lesions
Regurgitant
lesions
–Frequent Resp
Infections
–Precordial buldge
–Hyperkinetic
precordium
–Tendency for
sweating & CCF
–Shunt & Flow Murmur
–Plethric lung fields on
X Ray
–e.g ASD, VSD, PDA,
AP Window
-Forcible heaving
precordium
-Systolic thrill
-No cardiomegaly
-Delayed corresponding
component 2nd hearat
sound
-Ejection systolic
murmur
-Ventricular hypertrophy
on ECG
Generally
uncommon &
asymptomatic
e.g MR, AR, TR,
PR
77.
78. Acyanotic CHD : L → R
Shunts
Left parasternal
impulse
Wide, fixed split S2
Pulmonary ejection
systolic murmur
Tricuspid diastolic flow
murmur
rsR‘ in V1 in ECG
Atrial Septal
Defect
Left ventricular type
apial impulse
Systolic thrill
Pansystolic murmur
Mitral diastolic flow
murmur
LV dominance in ECG
Ventricular Septal
Defect
Wide pulse
pressure
LV type impulse
Systolic or
continuous thrill
Continuous
murmur
Mitral diastolic
flow murmur
Patent Ductus
Arterious
79. CONT…
•White arrow, right atrial
border;
•Purple arrow, right ventricular
border;
•red arrow, aortic notch;
•yellow arrow, pulmonary
artery;
•blue arrow, left atrial border;
•green arrow, left ventricular
border.
86. Acyanotic heart disease- Obstructive
Lesions
Right sided Left sided
Left parasternal
heave
Systolic thrill
Ejection systolic
murmur in upper left
sternal border
Wide split second
sound, delayed, well
heard P2
Pulmonary
Stenosis
Narrow pulse
pressure
Systolic thrill
Ejection systolic
murmur radiating
to neck
Delayed A2
Absent or weak, delayed
femorals compared to
radials
Arm blood pressure
high
Prominent carotids,
palpable aorta in
suprasternal notch
Palpable collaterals
Ejection murmur in
inter-scapular region
Aortic
Stenosis Coarcation of
Aorta
92. Cyanotic Congenital Heart Disease
With PS Without PS
No VSD With VSD Increased
PA pressure
Normal PA
pressure
Increased Pulm
blood flow
Decreased Pulm
blood flow
Pulm Venous
Obstruction
Cyanosis, Clubbing, Polycythemia
93. Cyanotic Congenital Heart
Disease
Cyanosis, Clubbing, Polycythemia
Pulmonary stenosis with right to left shunts at atrial level
Eg. Critical PS, Ebstein’s anomaly
Pulmonary stenosis with VSD – Fallot’s Physiology
Eg. TOF, Single ventricle, ECD, Hypoplastic RV
Increased blood flow with PAH – TGA Physiology
Eg. TGA, TAPVC, Tricuspid Atersia
Decreased pulmonary blood flow with PAH
Eg. Hypoplastic LV, Eisenmenger syndrome
Normal Pulmonary Artery pressure
Eg. TAPVC, Single Atrium, Pulmonary AV fistula.
94. CCHD - Pulmonary stenosis with
right to left shunts at atrial level
Prominent a waves – JVP
Parasternal heave
Cardiomegaly may be present
Systolic thrill ±
Cyanosis may be mild
Inter-costal retractions present
RVH with late transition in ECG
Critical Pulmonary
Stenosis
Quiet precordium
Heart size increased
Multiple sounds ± gallop rhythm
Scratchy systolic and diastolic
murmur
Characteristic ECG
Ebstein’s Disease
95. CCHD - Pulmonary stenosis with
VSD – Fallot’s Physiology
No Cardiomegaly, Mild left parasternal impulse, thrill
uncommon, S2 single, ejection murmur ends before S2,
Ischemic lungs
RAD, RVH: TOF, Single Ventricle
RAD, LVH: Single ventricle, Hypoplastic right ventricle
LAD, RVH: Single ventricle, ECD with PS
LAD, LVH: Tricuspid atersia, Single Ventricle
ECG
99. CCHD - Increased blood flow with
PAH – TGA Physiology
Neonate or infant, Failure to thrive,
Congestive failure
Cardiomegaly
Radioloically – Cardiomegaly with
pulmonary plethora
d-TGA, DORV, Tricuspid Atresia, Single
Ventricle, TAPVC, Misc. Malpositions
100. CCHD with Increased PBF
Complete transposition of great vessels
Double outlet right ventricle without pulmonary
stenosis
Tricuspid atresia with large VSD
Persistent truncus arteriosus
Single ventricle without pulmonary stenosis
Total anomalous pulmonary venous connection
Malpositions without obstruction to pulmonary
blood flow
101. Features of Eisenmenger
Physiology
History of frequent chest infection in infancy
Cyanosis present from birth or appears late
JVP – Prominent ‘a’ waves
No cardiomegaly or thrill
No parasternal heave
Constant ejection click of PHT
Second sound palpable, pulmonary component is
accentuated
Systolic murmur in pulmonary area
Pulmonary and/or tricuspid regurgitation murmurs may
be present
106. CONT…
Character
Collapsing pulse (water hammer pulse) jerky pulse with
full expansion followed by sudden collapse (AR, PDA, A-V
fistulas, anemia)
108. CONT…
Character
Pulses bisferiens (two strong systolic
peaks separated by a midsystolic dip)
seen in HCM, AS
Anacrotic pulse slow rising pulse in
A.S. (Parvus et tardus)
109. CONT…
Character
Pulsus paradoxus (amplitude decreases with
inspiration and increases during expiration) seen in
cardiac tamponade, COPD, massive P.E.
110. CONT…
Volume
Pulse Pressure – Difference between systolic and diastolic
blood pressure
Normal: 30 – 60 mm Hg
Bounding pulses are found in PDA, aortic regurgitation (AR),
large
systemic arteriovenous fistula.
Low Volume pulse – cardiac failure, shock.
112. CONT…
Jugular Venous Pressure
Although of little use in infants, in cooperative older children,
inspection of the jugular venous pulse wave provides
information about central venous and right atrial pressure.
The external jugular vein should not be visible above the
clavicles unless central venous pressure is elevated.
Increased venous pressure transmitted to the internal jugular
vein may appear as venous pulsations without visible
distention; such pulsation is not seen in normal children
reclining at an angle of 45 degrees.
Because the great veins are in direct communication with the
right atrium, changes in pressure and the volume of this
chamber are also transmitted to the veins. The 1 exception
occurs in superior vena cava obstruction, in which venous
pulsatility is lost