patient history and physical examination -...
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Tips in Patient History and
Physical Examination
PROF. ABDULLAH S. AL-JARALLAH, MD.
CONSULTANT PEDIATRIC CARDIOLOGIST
KFCC, KSU-RIYADH
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History
Demographic Data:
Name: Hosp No:
Age: DOB:
Sex:
Referring Hosp or clinic:
Care giver:
Complaint:
Detailed chronological events
Systemic review
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History (cont)
Past medical history
Prenatal:
Infection? radiation drugsantenatal care and ultrasound
Natal:
Where? When? apgar score
Post-natal:
when discharged home? why?first visit when? and who?
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History (cont)
Previous admissions and illnesses
Medications:
Cardiac non-cardiac
who give it
Allergies
Drugs environment
Immunization:
Nutrition:
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History (cont)
Growth and development: Social history:
Income transport home situation
help to mom
School
Family history: Pedigree similar case Cardiac
diseases Impact on the family
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Examination
General appearance:
higher functions
distress cyanosis pallor clubbing
dysmorphic features activity monitors lines
reaction parents attitude....
Growth chart:
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Examination (cont)
Vital signs:
Pulse all four limbs:
Blood pressure all four limbs:
Pulse Oxymetry:
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Pulses:
Pulses are the result of difference between systolic and diastolic status of the vasculature. Increase in the difference between
systole and diastole results in a more pronounced pulse.
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Cyanosis:
This is best determined by examining the patient in sunlight. Artificial light may alter patient color.
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Clubbing:
This is enlargement of the tips of digits caused by hypoxia to peripheral tissue due to poor cardiac output and/or cyanosis. Peripheral tissue
compensate by forming more capillaries to improve oxygenation, this results in swelling of the peripheries of digits.
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Formulas and General Rules
Children over 1 year old
Rough Approximations
Pulse or Heart Rate HR
Infant Pulse: 160
Preschool Pulse: 120
Adolescent Pulse: 100
Systolic Blood Pressure( SBP
Infant SBP: 80
Preschool SBP: 90
Adolescent SBP: 100
Respiratory Rate RR
Infant RR: 40
Preschool RR: 30
Adolescent RR: 20
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Examination (cont)
Cardiovascular: Inspection:
Palpation:
Percussion?
auscultation 1st and 2nd heart sounds
3rd (gallop) and 4th
murmur: site, phase, duration, radiation, intensity, grade
clicks
bruit: liver, renal, brain
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Maneuvers with auscultation
Supine, sitting and standing:
Increase pre-load in supine.........exaggerating flow murmurs
Valsalva maneuver:
Increase intensity of MVP
Decrease intensity of innocent heart murmurs
Respiratory cycle
Inspiration......increase blood flow to right heart
Expiration........increase blood flow to left heart
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Epidemiology Overall Murmur Prevalence:
50% of all children
Innocent murmurs more common than pathologic 10:1
Age of murmur onset related to pathology
Murmur onset at 24 hours of life: 8% pathologic
Murmur onset at 6 months of life: 14% pathologic
Murmur onset at 12 months of life: 2% pathologic
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Innocent Murmurs
Still's Murmur ( Aortic Vibratory Systolic)
Most common innocent murmur
Venous Hum of late infancy and early childhood
Second most common innocent murmur
Septal hypertrophy due to myocardial fat deposition
Resolves over six months
Pulmonary Flow Murmur
Neonatal Pulmonary branch murmur
Physiologic PPS
Supraclaviculr murmur
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Still's Murmur
First described by Dr. George Still (1909)
Epidemiology
Common in children ages 2 to 8 years old
Signs
Low to medium frequency, mid-Systolic Murmur
Intensity: Grade II-III of VI (variable)
Location: near apex
Character
Vibratory, harmonic, musical, twanging, groaning
Provocative conditions and positions (increased murmur)
Supine position
Fever
Anemia
Differential Diagnosis
Ventricular Septal Defect
Left ventricular outflow obstruction
Hypertrophic Cardiomyopathy
Course
Innocent murmur
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Pathologic Murmurs
Ventricular Septal Defect (VSD) 38%
Atrial Septal Defect (ASD) 18%
Pulmonary Valve Stenosis 13%
Pulmonary Artery Stenosis 7%
Aortic Valve Stenosis 4%
Patent Ductus Arteriosus (PDA) 4%
Mitral Valve Prolapse 4 %
Others 4%
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Examination (cont)
The back
Deformities thrill murmur
Neck:
JVP , visible pulsation and thrill,
web neck short
Liver and spleen:
Respiratory:
Air entry asymmetry wheezes
basal crepetations
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Examination (cont)
Abdomen: masses scars ..etc
Skin: rashes neurofibromatosis
heamangiomas depigmentations ..etc
CNS:
Cranial nerves motor sensory cerebellar function
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Examination (cont)
Muscle-skeletal:
Muscular dystrophy Joints deformity swellings pains
HEENT:
microcephaly, shunts....
Eyes: squint, cataract...
Ears: deafness, deformities, tagsthroat obstruction, adenoids, tracheostomy
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Provisional Diagnosis
after history 1,2,3...
limit it after examination to 1,2,3
Your differential diagnosis:
1-…………………..
2-…………………..
3-…………………..
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Ehlar danlos
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Marfan
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RH Fever
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Splinter hemorrhage
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Holt Oram
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MPS (Hurler's)
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Investigation
Plan what investigation will help you:
ECG,
CXR,
ECHO,
CATH
Others.
Explain to the child and his family what is going on
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