CATAD3

History

  • Maternal lupus- complete heart block.
  • Maternal rubella- PDA & peripheral PS.
  • Maternal HIV- infantile cardiomyopathy.
  • Birth asphyxia- cardiomyopathy.
  • Neonatal murmurs- AV valve regurgitation, semilunar stenosis.
  • Feeding problems- heart failure, ALCAPA, low cardiac output.
  • Feeding problems-
    • Frequent feeds- less than 2 hours.
    • Short feeds- less than 30 mins.
    • Sweating with feeding.
    • Dyspnoea with feeding.
    • Irritability with feeding.
  • Acrocyanosis is normal.
  • Constant central cyanosis is more likely cardiac than respiratory.
  • Alchohol- ASD, VSD.
  • Lithium- Ebstein’s anomaly.
  • Retinoic acid- conotruncal anomalies.
  • Valproic acid- ASD, VSD, AS, CoA, PA/IVS.
  • Cyanotic heart disease- unlabored tachypnoea.
  • Left sided obstructive lesions or respiratory illness- grunting and dyspnoea.
  • Exertional syncope- severe aortic obstruction, coronary anomalies, arrhythmia.

     

    Physical examination

  • Length of BP cuff bladder should be 80% of limb circumference.
  • Breadth of BP cuff bladder should be two third of limb segment length.
  • Doppler probe measures systolic BP.
  • Flush technique measures mean BP.
  • Orthopnoea- heart failure, pericardial restriction.
  • Right thoracotomy- BT shunt, ASD repair, mitral valve surgery.
  • Left thoracotomy- BT shunt, PDA ligation, coarctation repair.
  • Cyanosis needs arterial oxygen saturation less than 85% and desaturated Hb of 5 gm%.
  • Best indicator of cyanosis is the tongue.
  • In AR, patient nods yes while in TR he/she nods no.
  • TR- lateral head movement.
  • Absent arm pulse- classic BT shunt, subclavian flap repair of coarctation.
  • Bounding pulse- AR, PDA & AVM.
  • Most children have a soft S3.
  • Turbulent flow occurs at Reynold’s number > 2000.
  • Reynold’s number = (density x velocity x diameter) / viscosity.
  • Mechanisms by which turbulent flows produce murmurs-
    • Direct jet impact
    • Eddy currents
    • Bernoulli effect fluctuations &
    • Bubble formation.
  • AVM in an infant- unexplained cardiomegaly + bruit over liver or fontanel.
  • S1 has four components of which only the second and third are audible.
  • S4 is always abnormal.
  • Vascular ejection clicks are heard over the corresponding vessel.
  • Aortic valve click is heard at apex while pulmonary valve click is heard at LPSB.
  • Aortic valve click does not vary with respiration while pulmonary valve click is louder in expiration.
  • Smaller the VSD, higher the frequency of the murmur.
  • High frequency of EDM of AR is due to high diastolic pressure in the aorta.
  • EDM of PR is medium pitched except in PAH where it is high pitched.
  • Causes of mitral MDM are MS, MR, VSD and PDA. Also Austin Flint murmur and Carey Coomb murmur.
  • Causes of tricuspid MDM are TS, ASD and APVC.
  • Presystolic murmurs occur in true AV valve stenosis in sinus rhythm.
  • Continuous murmurs-
    • Aorto-pulmonary- PDA, BT shunt, bronchial collaterals, pulmonary vessels arising from truncus arteriosus.
    • Arteriovenous- AV fistula, coronary-cameral fistula.
    • Turbulent flow in arteries- CoA, peripheral PS.
    • Turbulent flow in veins- venous hum, obstructed APVC.
  • Continuous murmurs due to coronary- cameral fistulas may be louder in diastole.
  • Venous hums are best heard with patient upright.
  • To-and-fro murmur in absent pulmonary valve has a sawing quality.
  • Still’s murmur is an innocent low pitched musical MSM heard between LPSB and apex in children. It is different from the pulmonary flow murmur of childhood.
  • Pulmonary flow murmur of infancy is also called peripheral PS murmur and disappears by 6 months.

    CATAD3END