Cardiac History and Exam with Christina Ronai.
Hi, my name is Christina Ronai. I'm one of the Cardiology Fellows at Boston Children's
Hospital and I'll be talking to you today about the cardiac history and physical exam
when evaluating children for possible cardiac disease.
Our objectives today are to understand the clinical history relevant to heart disease
in children, recognize the features of the clinical exam in heart disease, understand
the basics of auscultation and characterization of cardiac murmurs, and understand the features
of pathologic versus benign murmurs.
Clinical History.
From a history standpoint, there are three important categories: gestational and perinatal
history, especially if evaluating an infant, postnatal and present history, and then family
history. We're going to go through each of these.
The gestational and perinatal history is really important when evaluating an infant. Specifically,
you're going to want to ask about the maternal history. Were they healthy while they were
pregnant? Did they receive prenatal care? And did they have regular ultrasounds during
pregnancy? And if so, did those show anything of concern?
When you're asking about maternal infections, you're referring mostly to the TORCH infections,
but any infection is also important to note. Finally, you're going to ask if mom took any
medications. Specifically, phenytoin, lithium, retinoic acid, and warfarin have all been
associated with cardiac malformations.
The postnatal and present history is our next category. Most importantly for infants and
young children is are they growing along their growth curve? And if they're not growing along
their growth curve, have they at least continued to consistently gain weight or have they been
losing weight? Are they meeting their developmental milestones? Have there been any feeding problems?
Is there any cyanosis?
Decreased exercise tolerance. Specifically for young children, you're going to want to
ask, as they run around on the playground, are they able to keep up with their peers
or are they falling back? Have they ever fainted or felt as if they were about to faint? Have
they ever experienced chest pain or palpitations? When you're asking about palpitations, I usually
pose the question to children have they had any extra beats or skipped beats?
The most important thing to remember when evaluating an infant is that feeding is really
an exercise test for them. And if they are able to feed and grow, there's usually not
a major cardiac issue.
Family history. You're going to want to ask if anyone has ever been born with a heart
problem. And that'll be your screening for family history of congenital heart disease.
Has anyone passed away suddenly or from an unexplained cause? Often I will also ask about
unexplained car accidents or drownings, because those can be indicative of electrical problems
with the heart. Does anyone have hypertrophic or dilated cardiomyopathy? And does anyone
in the family require a pacemaker or an implanted defibrillator?
Clinical Exam.
Next, we're going to move to the physical exam. The most important thing when you walk
in the room is to take in the general appearance of the infant or child.
From a nutritional standpoint, do they look well nourished or are they malnourished? In
terms of their respiratory status, are they breathing easily or are they breathing quickly
and with difficulty?
Then you're going to turn to palpation from the cardiac perspective. You're going to put
your hand on their chest and feel their precordium to see if they are hyperdynamic, is the point
of maximal impulse displaced, and do you feel a thrill? Then you're going to turn to peripheral
pulses.
In an infant, it's going to be really important to feel for the upper brachial pulse and the
lower femoral pulses. And note, are they bounding or is there a difference between the upper
and lower pulses? In addition, you're going to want at this point turn to the blood pressure,
which should in an infant or young child have been taken in both an upper extremity and
a lower one to make sure that there's no gradient.
Point of clarification. A systolic blood pressure measurement of greater than 10 millimeters
of mercury higher in the arm than the leg may signify the presence of a coarctation
of the aorta.
Then you're going to turn to auscultation.
Auscultation refers to the appreciation of the heart sounds. It's important to remember
that there are two big heart sounds, S1 and S2. S1 is going to refer to the mitral and
tricuspid valve closure. And S2 to the aortic and pulmonary valve closure. People often
talk about the splitting of S2. In normal children, it is normal to hear a variation
in the splitting with respiration.
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Abnormal Heart Sounds.
Abnormal splitting refers to when the S2 sounds are widely split, and that can be reflective
of volume overload or electrical delay in a right bundle branch block.
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Narrowly split second heart sounds usually are reflective of pulmonary hypertension or
aortic stenosis.
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And if the second heart sound is entirely single, that is reflective of severe aortic
stenosis, or pulmonary hypertension.
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This is a useful diagram for referring to the different areas that you'll listen to
the valves opening and closing. As you can see, there is an appropriate place to listen
for both the mitral, the tricuspid, and then the aortic, and the pulmonic.
Murmurs. Murmurs are the sound of blood moving through the heart. It's important to remember
that those can be benign, as in the sound of blood moving through an entirely structurally
normal heart, or the sound made by blood moving through abnormal valves or holes in the heart.
Murmurs are broken down into systolic, diastolic, continuous, gallops, and clicks. We will go
through each of these.
Before we do that, it's important to remember that we grade murmurs and that we are standardized
across all specialties into how we grade the murmurs. Grade I is barely audible. Grade
II is soft but easily audible. A grade III is moderately loud but accompanied by no thrill
when you put your hand on the precordium. Grade IV is loud and has a thrill. Grade V
is audible with the stethoscope barely on the chest, and grade VI is audible with the
stethoscope off the chest and very rare.
Systolic murmurs are divided into three categories: ejection, late systolic, and holosystoic.
Ejection murmurs are usually reflective of pulmonary stenosis or aortic stenosis. Late
systolic murmurs are usually reflective of mitral valve prolapse, and holosystolic murmurs
are usually tricuspid regurgitation, mitral regurgitation, or a ventricular septal defect.
This is a helpful chart in terms of breaking down the ways that systolic murmurs sound.
In a midsystolic murmur, you can hear that they're initially softer, then they get louder
and then softer again. Sometimes, that's referred to as a crescendo-decrescendo murmur.
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Holosystolic murmurs are heard throughout systole between S1 and S2 and can often actually
obscure the beginning of diastole.
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Early systolic murmurs are short and heard right at the beginning.
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And late systolic murmurs are usually reflective of mitral regurgitation and are usually accompanied
by a mitral click.
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Diastolic murmurs are always pathologic. They are broken into early diastolic and mid-diastolic.
Early diastolic murmurs are usually higher pitched and are reflective of aortic regurgitation
if it radiates to the apex, or pulmonary regurgitation if it radiates along the left sternal border.
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Mid-diastolic murmurs tend to be lower pitched, are appreciated with the bell of your stethoscope,
and they are mitral stenosis, which you hear at the apex of the heart, or tricuspid stenosis
at the left lower sternal border.
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Continuous murmurs are reflective of a PDA, an AV fistula, a shunt murmur after surgery,
or a venous hum. PDA are Patent Ductus Arteriosis murmurs and are usually appreciate in newborns
before the duct has closed.
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In addition, shunt murmurs are usually only heard after a child has had surgery.
Point of Clarification. A venous hum murmur varies with patient position, being louder
when the patient is sitting with their neck extended,
and softer or absent with the rotation of
the neck or when the patient is supine.
This is another diagram that is helpful for remembering
where you are going to hear each of the murmurs,
so an aortic valve stenosis murmur would be best appreciated in the aortic valve area,
which is in the right upper sternal border. Pulmonic murmurs are usually heard along the
left upper sternal border. Mitral murmurs are usually heard along the apex, and a VSD
or tricuspid regurgitation or Still's murmurs are heard at the left lower sternal border.
Point of Clarification. A Still's murmur has a characteristic vibratory quality,
and typically is louder when the patient is supine rather than sitting.
Gallops. Gallops are broken down into either S3 or S4. The third heart sound is referred
to as S3 and is usually heard at the apex of the heart.
Point of clarification. An S3 gallop is best heard at the apex if produced by a dilated
or dysfunctional left ventricle or along the left lower sternal border if produced by a
dilated or dysfunctional right ventricle.
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It can be normal in children and young adults. Although, it can also be reflective of patients
with dilated ventricles and decreased compliance. Fourth heart sounds are heard also at the
apex, and these are always part pathologic.
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Point of clarification. An S4 gallop is usually associated with decreased ventricular compliance
that occurs with myocardial ischemia or ventricular hypertrophy.
Clicks. Clicks. There are three types of clicks: ejection click, mid-systolic click, or the
diastolic opening snap. An ejection click is usually appreciated at the apex of the
heart. It is reflective of aortic stenosis, usually, if there's a bicuspid aortic valve
as well.
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Mid-systolic clicks are heard at the apex and usually reflect mitral valve prolapse.
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Finally, diastolic opening snaps are also mitral stenosis but are usually heard at the
apex or left lower sternal border.
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Rubs. A pericardial friction rub can be heard when the two walls of the pericardium rub
against each other, producing audible friction. This sound can be described as a grating,
scratching, or rasping noise that sounds similar to squeaky leather. It has both a systolic
and diastolic component and often obscures the normal S1 and S2 heart sounds. The sound
is usually best heard between the apex and the sternum and can be indicative of pericarditis,
which is an inflammation of the fibrous sac surrounding the heart.
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Thank you very much for your time today. I hope that you've enjoyed learning about the
cardiac history and physical exam.