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Congenital Heart Disease and Heart Murmurs template

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Description of Congenital Heart DiseaseDisease of the Cardiovascular system that occurs prenatally and becomes evident at birth, infancy, or young adulthood.Can be cyanotic or acyanotic
Risk Factors for Congenital Heart DiseaseFamily Hx Premature Birth Maternal exposure to alcohol, coxsackie B, cytomegalovirus, influenza, isotretioin, lithium, mumps, rubella, thalidomide, x-ray exposure during pregnancy, or other substances Associated with some chromosomal abnormalities Maternal age over 40 prenatal or perinatal fetal distress CHD in other siblings
Acyanotic Diseases of CHDAtrial Septal Defect Atrioventricular Septal Defect Ventricular Septal Defect Patent Ductus Arteriosus
Cyanotic Disease of CHDTransposition of the Great Vessels (Arteries) Tetrology of Fallot Tricuspid Atresia
Obstructive Diseases of CHDAortic Stenosis Pulmonic Stenosis Coarctation of the Aorta
Atrial Septal DefectMid-systolic Ejection Murmur Asymptomatic early in life Accentuation of tricuspid valve closure Wide Fixed S2 Arterial pulses = bilaterally Grade I-III/VI harsh murmur Easy fatigability Prone to respiratory infections May have delayed growth and development
Atrioventricular Septal DefectSystolic and Mid-diastolic murmur Frequent respiratory infections Delayed growth and developement, poor weight gain Wide split S2 Usually diagnosed in first year of life; often associated with Trisomy 21
Ventricular Septal DefectHolosystolic murmur Frequent respiratory infections Easy fatigability Delayed growth and development; poor weight gain Chronic heart failure frequently present; S3 audible Grade II-VI/VI murmur depending on severity Palpable left sternal border thrill
Patent Ductus ArteriosusSystolic and Diastolic murmur Poor weight gain Diaphoretic during feedings May present as soft, localized at left clavicle Murmur progresses to harsh, continuous, rumbling murmur Bounding pulses
Transposition of the Great ArteriesSystolic and Diastolic murmur Cyanotic Chronic heart failure Large for gestational age, but delayed growth and development
Tetralogy of FallotSystolic Ejection murmur Cyanotic Chronic heart failure "Tet" spells; cyanotic episodes precipitated by crying, feeding, and other activities Poor growth and development Squatting after exertion Easy fatigability Pale skin, poor turgor, clubbing Grade III-VI/VI harsh, murmur at 2nd ICS, left sternal border, with a thrill
Tricuspid AtresiaHolosystolic murmur Cyanotic Tachycardia Grade III-VI/VI harsh, murmur at left sternal border Poor growth, development, poor feeding, easy fatigability
Aortic StenosisSystolic Ejection murmur Grade III or IV/VI harsh murmur at upper right sternal border, rightneck, apex Weak peripheral pulses Easy fatigability Chronic Heart Failure
Pulmonic StenosisMid to late Systolic Ejection murmur Cyanotic Chronic Heart Failure Grade III-IV/VI harsh, murmur heard at upper left sternal border, transmission into both lungs, left neck
Coarctation of the AortaSystolic murmur Decreased blood pressure in lower extremities (upper extremity hypertension, lower extremity hypotension) Diminished pulses in lower extremities compared to upper extremities
Diagnostic Studies for Congenital Heart DiseaseChest X-ray Electrocardiogram Echocardiogram Arterial blood gas Angiographic studies
Non-Pharmacologic Management of Congenital Heart DiseaseDepends on severity Activity restriction Surgical repair Patient education
Pharmacologic Management of Congenital Heart DiseasePDA: Indomethacin helps consricts and close PDA TGA: Prostaglandin E1 to delay closure of the ductus until surgery
Follow-Up for CHDDepends on severity, age, and type of defect Careful attention to murmur at each visit; Consider referral to pediatric cardiologist for changes in murmur
Etiologies of Heart MurmursOrganic: Due to cardiovascular disease Functional: Disturbances produced within the cardiovascular system but which are due to other causes (ex. anemia, thyrotoxicosis, pregnancy) Innocent Murmurs: Disturbances which may or may not be cardiac in origin, but no cardiac disease is recognized as the cause
Assessing Heart MurmursTiming: Systolic or Diastolic, position in systole or diastole (early, mid, late, pan) Site: Point of maximal intensity, point of propagation Loudness: Grading Quality: Blowing, Harsh, Musical, Soft Shape: Decrescendo, Crescendo, Plateau, Diamond
Grading of MurmursGrade 1: Barely audible with intense concentration Grade 2: Faint, but audible immediately Grade 3: Moderately loud, no thrill palpable Grade 4: Loud with a palpable thrill Grade 5: Very loud, audible with part of the stethoscope off the chest, thrill palpable Grade 6: Audible without a stethoscope on the chest wall, thrill palpable
Innocent Murmurs (Still's, Venous Hum, Systolic Ejection)Most frequently detected in children and adolescents Soft, short, systolic, no other evidence of abnormality May be musical or vibratory Able to alter by maneuvers (standing, lying, posture change...) Varies in loudness from visit to visit Does not affect growth and development Left lower sternal border or pulmonic area are most common sites Normal S1 and S2, normal vitals
Types of Systolic MurmursAortic Stenosis Hypertrophic Obstructive Cardiomyopathy Pulmonic Stenosis Mitral Valve Insufficiency Tricuspid Regurgitation Ventricular Septal Defect
Aortic Stenosis MurmurSystolic Ejection (Mid systole) Most frequently heard in elderly pts Heard best in 2nd ICS to the right of the sternum Sound radiates to right clavicle and transmitted to both carotid arteries Systolic thrill may be present
Hypertrophic Obstructive CardiomyopathyLate systolic Best heard at the lower left sternal border Increases with Valsalva maneuver, standing Crescendo/ Decrescendo murmur Usually does not radiate to neck, but biphasic carotid pulse
Pulmonic Stenosis MurmurMid Systolic Murmur Heard best at 2nd ICS left sternal border Does not radiate like aortic murmur Variable click audible
Mitral Valve InsufficiencySystolic murmur Mitral valve prolapse may not produce murmurs(mid to late systolic cycle) Mitral regurgitation is holosystolic Best heard at apex of heart with pt in left lateral decubitus position Radiates toward left axilla Varies in intensity
Tricuspid RegurgitationSystolic murmur Best heard at left lower sternal border, over the xiphoid, sometimes over the liver Increases in intensity with inspiration Regurgitant "v" waves in the neck veins
Ventricular Septal DefectHolosystolic murmur Best heard at left sternal border, 4th ICS Often harsh The greater the gradient, the louder the murmur
Diastolic MurmursAlways considered abnormal Tend to be softer than systolic murmurs Best heard with bell of stethoscope because of low pitch
Types of Diastolic MurmursMitral Stenosis Tricuspid Stenosis Aortic Regurgitation Pulmonic Regurgitation
Mitral StenosisMid-Diastolic murmur Low-pitched apical murmur Best heard after mild exercise and pt in left lateral decubitus position May be isolated to the apex beat site Does not radiate
Tricuspid StenosisEarly Diastolic Murmur Best heard in the 4th or 5th ICS left of the sternum, xiphoid, or apex Increased in duration and intensity by exercise, inspiration, sitting forward Decrescendo murmur
Aortic RegurgitationEarly Diastolic Murmur Blowing, high-pitched, decrescendo murmur Best heard at left sternal border and toward the apex
Pulmonic RegurgitationDiastolic Murmur High-pitched decrescendo murmur Radiates to apex Heard loudest at 2nd ICS at sternal border
Types of Continuous MurmursPatent Ductus Ateriosus Coarctation of the Aorta
Patent Ductus ArteriosusHeard throughout systole and diastole Bounding pulses
Coarctation of the AortaHeard throughout systole and diastole Weak femoral pulses
Diagnostic Studies for MurmursElectrocardiogram Chest x-ray Doppler echocardiography Angiography
Nonpharmacologic Management of Heart MurmursSurgical Repair (palliative) Pt education
Consultation/Referral for Heart MurmursRefer all new, non-innocent murmurs to cardiologist

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