ClinicalCoreConference:

PediatricCardiacEvaluation

PatrickA.Flynn,M.D.
DivisionofPediatricCardiology
Weill CornellMedicalCenter

AsfacultyofWeillCornellMedicalCollegewearecommittedto
providingtransparencyforanyandallexternalrelationshipsprior
togivinganacademicpresentation.

Patrick A. Flynn, M.D.

IDONOThaveafinancialinterestincommercial
productsorservice.
FinancialrelationshipsandthecompanieswithwhomIhave
relationshipsarebelow:

None

But
WhenIreadanechocardiogram(forfree)for
MemorialSloanKetteringCancerCenter,the
techsendsmeasmallbagofcandy(usually
ReesescupsandYorkPeppermintPatties),
whichI(sometimes)sharewithmystaff
justincasethatcounts

Normalcardiacanatomy
Postnatal

Prenatal

Cardiacevaluation
History
Familyhistory

PhysicalExam
Vitalsigns
Inspection
Palpation
Auscultation

Ancillarytests

History:
GeneralInformation
Establisharelationshipwiththepatientand
theparents(inthatorderifpossible)
Firstimpressionsarelonglasting
Manyhavepreconceivednotions
Fearisthepredominantemotion
Honestyiskey!!
Positive,nonconfrontationalinteraction
Agespecific talktoeveryone

History
Postnatal
Weightgain
Feeding
Ounceswithfeedingandlengthoffeeding
Tachypneaordiaphoresis

Respiratoryinfections
Cyanosis
Squatting
Endurance
Chestpain,syncope,palpitations

FamilyHistory

Congenitalheartdisease
Earlysuddencardiacdeath
Marfans
Rheumaticfever

PhysicalExam
VitalSigns
Inspection
Palpation
Auscultation

PhysicalExam:
Vital Signs
HeartRate
RespiratoryRate
Bloodpressure
rightarmandatleastoneleg
bladderofBPcuffshouldbe80%oflimbcircumference
and2/3oflengthofextremity
listeningforKorotkoffsounds,palpation,Doppler,orflush
techniquescanallbeused

OxygenSaturation(rightarmandoneleg)
Weightandheight

PhysicalExam:
Inspection
Generalappearance(comfortable,fussy,
nutritionalstatus,dysmorphicfeatures)
Color(pink,centralvs.acrocyanosis,pale)
Breathingpattern(tachypnea,dyspnea,
grunting,nasalflaring,retractions,headbobbing)
Neckveins(patientat30upright)
Chest(sternotomyorthoracotomyscars,chest
walldeformities,symmetry,precordialbulge,PMI)
Extremities clubbing,edema

PhysicalExam:
Palpation
Washyourhands!!!!!
Pulses(rate,regularity,quality,upperand
lowerextremitieswithbrachiofemoraldelay)
Capillaryrefilltime
Chest
PMI ventriculardimension
Precordialactivity volumeorpressureloads
Thrills vibrationdistaltojetlesions

Abdomen
Dothislastwithkneesbent
Sizeandtextureofliverandspleen
Responseofvitalsignstopalpation

PhysicalExam:
Auscultation
Developaroutineandstickwithit!!
RUSB,LSB,apex,leftsub claviculararea,
bothaxillae,liver,head,back
S1,S2,extrasounds
Listentopatientindifferentpositions

Apt. M.

PhysicalExam:
Auscultation Normal
S1 closureofmitralandtricuspidvalves
S2 closureofaorticandpulmonicvalves
A2precedesP2
S2varieswithrespiration

S3 earlydiastolicventricularfilling
Lowfrequencysoundbestappreciatedwithbellat
apexorLLSB
Frequentlyheardinnormalkidsandcompetitive
athletes

PhysicalExam:
Auscultation Abnormal
S4 Lateventriculardiastolicfilling
Alwaysabnormal
Lowfrequencysoundattheendofdiastole
Associatedwithrapidfillingofventricleduringatrial
contraction
Heardinpatientswithheartfailureandinconditions
withdecreasedventricularcompliance

S3 canbelouderthannormalwithdecreased
ventricularcompliance

PhysicalExam:
Auscultation Abnormal
Clicks heardsoonafterS1
Associatedwithsemilunarvalvestenosis(aorticand
pulmonicstenosis)
ASheardbestatRUSBorapex
PSheardbestalongLSB

Clicks heardinmidsystole
Associatedwithmitralvalveprolapse
Hearbestatapex

PhysicalExam:
Auscultation Murmurs
Intensity(loudness)
Timing
Location
Transmission
Quality

Murmurs:
Intensity
GradeI Barelyaudible
GradeII Soft,easilyaudible
GradeIII Moderatelyloudwithout athrill
GradeIV Moderatelyloudwith athrill
GradeV Loud,heardwithstethoscopeonitsside
GradeVI Loud,heardwithoutthestethoscope

Murmurs:
TimingDuringCardiacCycle
Systolic
Diastolic
Continuous

InnocentMurmurs:
Normal Functional Benign Physiologic
Soundofnoisybloodflowcoursingthroughastructurally
normalheart almostalwayschangeswithpositioning
Heardin5090%ofpeopleatsometimeintheirlife,most
commonlyatage34years
Accentuatedbyincreasedcardiacoutput(whenachildis
excited,anemic,orfebrile)
Auscultationisdiagnosticmethodofchoice
Exactcausehasyettobedefined:

InnocentMurmurs:
StillsMurmur
Mostcommoninnocentsystolicmurmur
ofchildhood(28years)
Midsystolicmurmur
Heardinthebenigntriangle
Describedasmusicalorvibratory
UsuallyIIII/VIingradingintensity
Twangingofpapillarymuscles/chordae

InnocentMurmurs:
PulmonaryFlowMurmurofChildhood
Commonlydescribedinthinadolescents
betweenage814years
HeardbestatLUSB
ResemblesejectionmurmurofPSbutnot
accompaniedbyaclickorathrill,anddoes
notradiatetoback
CanbeIIII/VIingradingintensity
P2componentofS2isnormal

InnocentMurmurs:
PulmonaryFlowMurmurofInfancy
AlsoreferredtoPeripheralPulmonaryStenosis(PPS)
Commonlyheardduringthenewbornperiod,especiallyin
prematureinfants
EjectionmurmurheardbestatLUSBradiatingtobilateral
axillaeandtheback
Thoughtobecausedbysmallsizeandacuteangleoftakeoff
ofbranchPAsfromthemainpulmonaryartery
Usuallydisappearsbyage6months
Ifitpersistsbeyond6months,structuralabnormalitiesof
thepulmonaryarterytreeshouldbeconsidered

InnocentMurmurs:
VenousHum
Commonlyaudibleinchildren36yearsofage
Continuousmurmur
Maximallyaudibleatrightand/orleftinfraand
supraclavicularareas
Heardonlyupright,disappearswhensupine
Dissipateswithheadrotation
Originatesfromturbulenceinjugularvenoussystem

InnocentMurmurs:
SupraclavicularBruit
Highpitchedsystolicmurmur
IIII/VIingrading
Heardbestinsupraclavicularareaandmay
radiatetolowerneck
Accentuatedbylightpressureonsubclavian
artery,butdisappearswithfirmpressure,with
raisingchin,orwithmovingshouldersback
Causedbyturbulentflowattakeoffof
brachiocephalicvessels

Cardiologytoolbox

ECG
Echocardiogram
CXR
Holtercardiogram
Stresstest
Eventrecorder
Cardiaccatheterization
CT/MRI

1yearoldwithaPDA

Whatstheproblem??
History
Exam

8montholdwithPS

Whatstheproblem??
History
Exam

5yearoldwithanASD

Whatstheproblem??
History
Exam

1yearoldwithaVSD

Whatstheproblem??
History
Exam

2montholdwithTOF
Whatstheproblem??
History
Exam