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CHD occurs in how many births
8/1000
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Critical CHD (death, cardiac catherization, surgery) occurs in how many births?
3/1000
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Grades of cardiac murmurs
1-6
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Soft readily heard
Grade 2
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Moderatly loud, no thrill
Grade 3
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Loud murmur w/ thrill
Grade 4
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Heard w/o complete contact of stethoscope
Grade 5
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Heard w/o stethoscope on chest wall
Grade 6
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4 causes of Systolic Ejection Murmurs
- Aortic Stenosis
- Pulmonic Stenosis
- Flow murmurs/Stills murmurs
- ASD
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Systolic Murmurs: Holosystolic or regurgitant murmurs
- VSD
- Tricuspid/Mitral Regurgitation
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Diastolic murmurs: Regurgitant-decrescendo
- Aortic insufficiency
- Pulmonic insufficiency
- Starts w/ high frequency and decreases in frequency and intensity as pressure gradient causes regurgitant flow decreases
- Begins w/ S2 and continues slightly beyond S1
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Diastolic Murmurs
- Diastolic Flow murmur-early (flow)
- Mitral Stenosis
- Tricuspid Stenosis
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Early diastole low frequency low intensity, no significant pressure gradient
Tricuspid stenosis
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Continuous Murmur: Venous hum
- Most common
- Normal but turbulen flow at confluence of innonimate veins entering SVC
- Best heard at upper riht sternal border in sitting position
- Changes w/ turning of head and may disappear when supine
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Continuous murmur with a pressure gradient between AO and PA
PDA
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Where are PDAs best heard?
Left upper sternal border (not positional)
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Arterial pulse waveform showing alternating strong and weak beats. Almost always indicates left ventricular systolic impairment; poor prognosis.
Pulsus Anternans
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Pulsus anternans almost always indicates
Left ventricular systolic impairment
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Exaggeration of the normal variation during inspiration, in which the blood pressure declines as one inhales and increases as one exhales
Pulsus paradoxus
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Pulsus paradoxus indicates
- Cardiac tamponade
- Pericarditis
- Chronic sleep apnea
- Croup
- Obstructive lung disease
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Can detect beats on cardiac auscultation during inspiration that cannot be palpated at the radial pulse
Pulsus paradoxus
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Metabolic Syndrome Cardiac Risk Factors
- Obesity
- Dyslipidemia
- Diabetes
- HTN
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Diminished or absent femoral pulses
Coarctation of the aorta
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Bounding or water hammer pulses
Aortic regurgitation
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Narrowing of the aorta
Coarctation of the aorta
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Is coarctation more common in boys or girls?
Boys
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Coarctation is very common in what syndrome
Turner Syndrome
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Coarctation typically occurs where?
After the left subclavian artery
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Clinical Presentation of CHD in Neonate (Timing and Symptoms depend on)
- Anatomic defect
- In utero effects (if any)
- Physiologic changes- transitional circulation, closure of the ductus arteriosus, fall in pulmonary vascular resistance
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Minimal symptoms that present within first 2-3 days of life; duct dependent pulmonary blood flow
Cyanosis
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Presents within first 2 wks of life; duct-dependent systemic blood flow
CHF/Circulatory Collapse/ Shock
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Hyperoxia Test: pO2 <100
Cyanotic CHD likely
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Hyperoxia Test: 100-250
Cyanotic CHD possible
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Hyperoxia Test: pO2 > 250
Cyanotic disease unlikely
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Neonatal emergency, urgent intervention required
Failed hyperoxia test
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Conotruncal defect that has a microdeletion 22
Truncus Arteriosus
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Clinical syndrome in which the heart is unable to perform its pump function to meet metabolic demands of the body
Congestive Heart Failure
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2 things that result in CHF
- 1) increased demaned volume or pressure overload
- 2) normal demand but increased ability; inflammatory or metabolic disease
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After 2 day, the neonate who presents w/ circulatory collapse in the first few weeks of life has
Duct dependent systemic blood flow until proben otherwise. (Coarctation of the aorta, Interrupted aortic arch, Critical aortic stenosis, hypoplastic left heart syndrome)
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Hypoplastic left heart syndrome
1/5000
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Erb's point
3rd left intercostal point, hear aortic valve murmurs
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PMI is found
Lateral heart border, usually just inside the mid-clavicular line
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4th intercostal space
Straddles the atria
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5th important marker
Most inferior portion of left ventricle
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ERBs is where what murmurs are best heard
aortic
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4th intercostal space
tricuspid valve
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5th intercostal space
mitral
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Heart Sound: Closing event of mitral and tricuspid valves
S1
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Heart Sound: Closing event of aortic and pulmonic valves
S2
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S4 is only with contraction of what?
atrial
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Heart Sound: Occurs during end of rapid ventricular filling
S3
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Another word for S2
Incisura
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Decreased compliance of the corresponding ventricle
Diastolic stiffness (S4)
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Heart sound indicates systolic dysfunction/systolic failure
S3
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Diastolic sound- S3 or summation sound
Gallop
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Clicks during systole
Systolic gallop
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Pseudohypertension
Osler's hypertension
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Characteristic Pulse: Late and weak
Pulsus tardus et parvus
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Characteristic Pulses: Water hammer
Corrigan's Pulse
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Characteristic Pulses: Twice beating
Pulsus bisferiens
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Characteristic Pulses: Two heartbeats close together by a bigeminus
Pulsus bigeminus
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Characteristic Pulses: Aortic insufficiency and stenosis together
Pulsus Bisferiens
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3 things that commonly have Pulses paradoxus
COPD, apnea, tamponade
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Pulsus alternans is common in
heart failure
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Allen's Test for functioning Palmar Arch
Massage blood out of palm, occlude radial and ulnar artery into hand. Ensures that there are superficial and deep palmar artery arch overlap
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Kussmaul's Sign
Jugular venous distention on inspiration
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How do you convert cm of blood to mmHg
Multiply by 0.7.
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Noise from an artery or vein
Bruit
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Noise from the heart
Murmur
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Bruit or murmur you feel
Thrill
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Innocent or abnormal murmur
Systolic murmur
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Abnormal murmur
Diastolic murmur
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Innocent murmurs are usually soft, and most due to flow across _______. Common in ____.
Pulmonic outflow tract
Children, during fever, anemia, pregnancy or any state w/ increased cardiac output.
Normal respiratory response of the second heart sound.
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Often equated w/ obstruction at aortic or pulmonic valve
Ejection Murmur
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Diamond Shaped
Ejection murmur (start quiet, get loud, get quiet again)
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Causes all murmurs
Ejection , either forward or backward
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Cardinal Symptoms of Aortic Stenosis
- Dyspnea
- Angina pectoris
- Syncope
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Heyde's Syndrome
Intestinal bleeding associated with aortic stenosis
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Gallavardin phenomenon
Found in aortic stenosis (separation of sounds)
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Absent or weak A2
Calcification of cusps
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Which comes first in an S2 split
Aortic (Anatomy before Physiology)
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S1 sound is not due to closure of valve
It is due to events that bring about the closure
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In moderate to severe aortic stenosis you will hear
Thrill
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Sawing wood murmur, usually grade 2-3 intensity
Aortic Stenosis, absent in tight stenosis
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Name 2 sounds common in aortic stenosis
S4, aortic diastolic murmur
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Sign found in patient's with Tricuspid regurgitation
Carvallo's sign
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Pansystolic murmur becomes loud in inspiration
Carvallo's sign= tricuspid regurgitation (differs it from mitral regurgitation)
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Thrill w/ murmur that begins early and masks S1 and extends well beyond S2
VSD
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Machinery-like murmur
PDA
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Holosystolic
Mitral regurg., Tricuspid regurg., VSD
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Diamond-shaped murmurs
Aortic or pulmonic stenosis
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High pitched diastolic murmur in Erb's area
Aortic regurgitation
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de Musset's head bobbing
Duroziez's to and fro femoral bruit
Traube's pistol shot sound
Aortic regurgitation
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Aortic regurgitation that mimics mitral stenosis
Austin Flint murmur
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Where is Aortic regurgitation best heard
Right sternal edge
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Common cause of Aortic regurgitation
Rheumtic (congenital, degenerative)
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Aortic root disorders that lead to an enlarged aorta and aortic regurgitation
Cusp rupture (Marfan's, Syphilis)
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4 Stages of Valsalva's Maneuver
- Stage 1: LV transient stroke volume & BP increase (4-5 seconds)
- Stage 2: LV stroke volume falls - BP falls- heart rate speeds (CO = SV * HR)
- Stage 3: Release- blood sucked back in to the lungs- compensatory overshoot of BP- HR falls
- Stage 4: Return to baselin
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Murmurs that increase during Valsalva's Maneuver
Murmurs of hypertrophic cardiomyopathy and mitral valve prolapse
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Valsalva's maneuver:
Heart rate _______
Stroke volume is _____
- Increases contractility
- Decreased
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Murmurs that decrease during Valsalva's maneuver
Aortic and pulmonary stenosis
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Barlow's Syndrome
Mitral Valve Prolapse
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Mid-systolic click
Mitral valve prolapse
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Regurgitation in an individual with floppy mitral valve. 3rd sound and diastolic flow murmur indicating severe regurgitation
Barlow's Syndrome
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Loose jointed/ hypermobility is indicative of
Mitral Valve Prolapse
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Ehler's Danlos
Mitral Valve Prolapse
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Ejection sound and preserved second sound (A2) reflect mobility of the valve despite severe stenosis
Congenital bicuspid valve (Pulsus parvus et tardus)
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Fixed S2=
Wide S2 splitting=
- Fixed S2= ASD
- Wide S2 splitting= normal in inspiration, abnormal in expiration
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