APPROACH TO THE

DIAGNOSIS OF HEART
DISEASES IN CHILDREN

History and Physical Examination

Edgardo E. Ortiz, MD, MHSA, FPPS, FPCC, FAsPCC
Professor and Chair
Department of Pediatrics
College of Medicine-Philippine General Hospital
University of the Philippines Manila

Approach to Heart Diseases
in Children
Congenital vs. Acquired?
History
Physical Examination
Chest X-Ray
EKG
2DEchocardiography
History
Maternal & Birth

Family

Past
Maternal History
Infections

Medications

Alcohol intake
Maternal History
Infections: 1
st
trimester of pregnancy

1. German measles - Congenital Rubella
Syndrome; PS; PDA
2. Cytomegalo virus - teratogenic
Herpes myocarditis last trimester
Coxsackie B
Maternal History
Illness
1. DM - cardiomyopathy (ASH)
- structural (VSD, TGA,PDA)
2. SLE - Heart Blocks
3. CHD - 15% incidence of CHD
( vs 1% general pop.)

Maternal History
Medications
1. Amphetamines (uppers) VSD, PDA, ASD, TGA
2. Anticonvulsants
a) Diphenylhydantoins PS, AS, COA
b) Trimethadione TGA, TOF, HLHS
3. Progesterone/Estrogen VSD, TGA, TOF
Alcohol - Fetal Alcohol Syndrome
- VSD, PDA, ASD, TOF
Past History
1. Cyanosis including spells
2. CHF
3. Weight gain/feeding
4. Heart murmur
5. Frequent Respiratory Infections
(lower)

Cyanosis - deep & fast breathing
vs
Breath holding spell - holding breath

Cyanosis birth (or 2 wks of life)
emergency
CHF
Onset

L R

TGA etc
CHD
Weight affected more than the height

Weight severely affected dysmorphic
conditions
Past History
Others:

Chest pains

Joint swellings

Neurologic symptoms
Family History
Hereditary Disease
Congenital Heart Disease
___________
RF
Hypertension/Atherosclerosis
Family History
Hereditary

Holt Oram AD ASD
Marfans AD AR/IMR
Williams AD supra valvar AS/ PA steins

Family History
CHD
Incidence in general population 8 to
12/1000 live births
Recurrence Risk related to recurrence
risk of the syndrome or H.D.
One child affected risk recurrence in
sibling 3% (VSD)
2.5 % (TOF)
Family History
Defect Mother Affected
(%)
Father Affected
(%)
Aortic stenosis 13.0 -18.0 3.0
Atrial septal defect 4.0 4.5 1.5
Patent ductus arteriosus 3.5 4.0 2.5
Tetralogy of Fallot 6.0 10.0 1.5
Ventricular septal defect 6.0 2.0
Approach to Heart Diseases in
Children
Congenital vs. Acquired:
HISTORY
Maternal and family history
Age of onset of symptoms
<2 yrs congenital
2-5 yrs congenital/acquired
>5 yrs - acquired
Exceptions:
CHD w/ late onset manifestations
Acquired heart diseases in the young
Congenital Heart Disease
Normal
Heart
Congenital Heart Disease
Congenital Heart Disease
Normal Cardiac Chamber
Oxygen Saturations
Inspection and Observation
General appearance
Comfortable , playful
Breathing pattern
Cardio-pulmonary distress
Color
Pink, pale or cyanotic
Nutritional status
Normal
Malnourished
undernourished or obesity

Genetic abnormalities




Cyanosis
5 gm% of desaturated Hb
Bluish discoloration of
nailbeds, skin, oral mucosa
Difficult to detect if 0
2
sat >
85% or anemia
Central vs. peripheral
cyanosis hyperoxic test
Needs immediate
intervention in neonates

Inspection and Observation
Nutritional status
Normal
Malnourished
undernourished or
obese




Inspection & Observation :
Genetic Abnormalities
Trisomy 21
Trisomy 13
Trisomy 18
Inspection: Head
Head bobbing
Severe AR
Eyes
Cataract, congested
conjunctivae,
hypertelorism
Face
edema
Mouth
Color of lips & tongue;
teeth, tonsils


Inspection & Palpation : Neck
Back of the neck
Acanthosis nigricans ; looseness;webbing
Pulsations
Arterial : carotid aortic run-off lesions
Corrigans pulses
Venous : jugular
Normal
Distended : severe TR
Engorged Jugular Vein
Inspection & Palpation : Chest
Normal
Adynamic precordium
Apex beat
Point of maximal impulse
Abnormal
Retractions
Dynamic, hyperactive
Precordial bulge
Pectus excavatum &
carinatum
Harrisons groove


Inspection & Palpation : Chest
Sternal retraction
- poor lung compliance
Inspection & Palpation : Chest
Subcostal retraction airway obstruction or
pulmonary congestion
Chest Deformity
Pectus Carinatum Pectus Excavatum
Inspection & Palpation: Chest

1/M with moderate size
VSD became smaller
Dynamic precordium
Precordial bulge
Harrisons groove
Thrill
Inspection & Palpation: Chest

Apex beat most
lateral cardiac
impulse


Point of maximal
impulse
Inspection & Palpation: Chest
Palpation: Chest
Heave
Impulse with double contour : volume
overload
Tap
Well localized sharp rising impulse : pressure
overload
Apex Beat
Palpation : Chest




RV Heave
Subxiphoid impulse
Palpation : Chest
Thrill
Vibration detected distal to jet lesions from
cardiac defects ; loud murmur
LUSB : Pulmonary stenosis, PDA , VSD ,AS
LMSB : PS, VSD
LLSB : VSD, TR
Apex : MS, MR

Inspection & Palpation:
Abdomen
Distension ascites
Pulsatile abdominal aorta aortic run-off
Liver
Infants : soft palpable 2 3 cm BRCM
1 year old : 2 cm & 4 5 years old : 1 cm
Hepatomegaly : hallmark of systemic venous
congestion in infants
Pulsatile liver : TR or inc. RA pressure

Inspection & Palpation :
Extremities
Marfans syndrome
Thumb Sign
Wrist Sign
Arachnodactyly
Inspection & Palpation :
Extremities
Edema : not common in infants with heart
disease; usually due to presence of TR

Inspection & Palpation :
Extremities
Hands & feet
Cyanosis : clubbing of fingers & toes

Inspection & Palpation :
Extremities
Hands & feet :Differential cyanosis
Hands pink & feet cyanotic PDA with severe
pulmonary HTN
Hand cyanotic & feet pink TGA with
coarctation
Palpation : Pulses
Rate
Regularity
Quality :
Rate of rise
Pulse volume
Fast & brisk : VSD, MR
Fast & large: PDA, AR, severe anemia
Palpation: Pulses
Simultaneous palpation of
peripheral pulses
delay in lower extremities is
suggestive of coarctation

Abnormal Pulses
Pulsus paradoxus
> 10 mmHg difference in
SBP during expiration &
inspiration
Seen in constrictive
pericarditis,cardiac
tamponade

Pulsus alternans
Traubes sign
Alternating strong & weak
pulses
Severe LV failure
Blood Pressure
Can be uncomfortable
Cuff size : inflatable
rubber bag covers 2/3
of upper arm ; width
half of upper arm
circumference ;
smaller bag falsely
elevated BP

Blood Pressure
Systolic BP : 1st Korotkoff
sound
Diastolic BP : 5th
Korotkoff sound
BP lower extremities >
upper by 10 mm Hg
normally ; if
upper > lower by 10 mm
Hg , coarctation of aorta

Normal BP by Sex & Age
HEART MURMURS
Timing
Intensity
Duration / Type
Location
HEART MURMURS
Timing
Systolic
Diastolic
Systolic-diastolic
Continuous
S1
S2 S1
HEART MURMURS
Intensity: Grade I-VI
Significant: Grade III or louder
Duration: short or long
Type: systolic ejection
pansystolic/holosystolic
SEM - obstruction
HSM - regurgitation
HEART MURMURS
Location
RUSB LUSB
LPSB
APEX
HEART MURMURS
Ejection
AS PS/ASD
HEART MURMURS
Holosystolic
VSD/TR
MR
HEART MURMURS
Base - Congenital
Apex - Acquired
Heart Disease Screening
The 3-minute assessment (GAp CApE)

1. General Appearance - GAp
2. Chest Examination - C
3. Abdominal Palpation - Ap
4. Extremity Examination - E
General Appearance (30 seconds)
Cyanotic or not?
Facies?
Tachypnea/Dyspnea/Diaphoretic?
Failure to thrive?
Chest Evaluation (1 minute 30 seconds)
Subcostal retraction?
Apex beat displacement/precordium?
Murmur?
Rales ?
Abdominal Palpation (20 seconds)
Liver enlarged?
On the left?
Extremity Examination (40 seconds)
Skin - smooth & dry or clammy?
Pulses - Both upper equal?
Both lower equal?
Capillary refill?
Clubbing?