Cardiovascular Consequences of Sleep-Disordered Breathing
Mark A. Richardson, Norman R. Friedman in Clinician’s Guide to Pediatric Sleep Disorders, 2016
Clinical evaluations of children with suspected SDB should include a thorough medical history. Particular focus should be given to a prior history or symptoms of congenital or acquired cardiovascular disease. A complete physical examination should assess for clinical signs of cardiovascular system involvement. Physical exam findings suggestive of cardiac dysfunction include hypertension, hypotension, jugular venous distension, hepatomegaly, and peripheral edema. Cardiac auscultation should evaluate for the presence of rhythm irregularities, valvular flow murmurs, as well as prominence of the second heart sound. This latter finding may suggest elevation of pulmonary artery pressures. Additional findings that may necessitate more through cardiac evaluations may include the presence of prominent developmental delay, failure to thrive, or complex genetic or neuromuscular conditions. Beyond the medical history and physical examination, assessments should be tailored to the individual patient and the index suspicion for cardiac involvement (Table 2)
Pressure waveforms in the cardiac cycle
John Edward Boland, David W. M. Muller in Interventional Cardiology and Cardiac Catheterisation, 2019
Valve motion causes a series of characteristic heart sounds that can be detected by auscultation or phonocardiography, as described in Figure 14.7b. The atrioventricular valves close with a loud slap at the very beginning of ventricular systole: This is called the first heart sound. The aortic and pulmonary valves close audibly when systole ends: This is called the second heart sound. To a certain extent the first and second heart sounds may be ‘split’, due to asynchronous closure of the mitral/tricuspid or aortic/pulmonary valves. This splitting is more marked on inspiration and is usually never wide (<0.03 seconds). Wide splitting of the second sound may occur in right bundle block, pulmonary stenosis, atrial septal defect, or anomalous pulmonary venous drainage (the last two causing fixed splitting). Paradoxical splitting of the second sound may occur in tetralogy of Fallot and truncus arteriosus.
Valvular heart disease
Ian Mann, Christopher Critoph, Caroline Coats, Peter Collins in The Junior Doctor’s Guide to Cardiology, 2017
Classically on examination there is an ejection systolic murmur which radiates to the carotid arteries. The loudness is not related to severity. In fact in severe AS the murmur is often quiet and S2 is inaudible due to restricted valve motion. It may be difficult to hear the murmur in the setting of heart failure. Clinical markers of severity include the following: narrow pulse pressurepalpable thrill in the aortic areasoft S2long murmurdelayed A2 or reversed splitting of heart sounds.
Digital devices for teaching cardiac auscultation - a randomized pilot study
Published in Medical Education Online, 2018
Malcolm E. Legget, MeiYen Toh, Andries Meintjes, Sarah Fitzsimons, Greg Gamble, Robert N. Doughty
Digital stethoscopes and hand-held echocardiography (HHE) devices are modern portable digital devices that allow physicians to evaluate patients with heart murmurs. Digital stethoscopes provide improved sound quality and the ability to record and play back sounds multiple times to multiple listeners [1]. HHE devices provide real-time visual display of cardiac valvular pathology at the patient bed-side. While well established as tools that help in the clinical assessment of patients, these tools also have the potential to facilitate effective teaching of cardiac auscultation, a core skill integral to clinical medicine. A conventional stethoscope’s inability to act as an ‘audio platform’ may be a significant obstacle to the effective teaching of cardiac auscultation [1]. The use of digital stethoscopes and HHE as teaching aids to improve the diagnostic accuracy of evaluation of heart murmurs, compared to conventional bedside examination, has not yet been evaluated in depth.
Digitalising medical education: sacrificing skills for knowledge?
Published in Medical Education Online, 2019
Cardiac auscultation is a subtle sensory skill that is often found difficult by many medical students. As such, using technological aids in teaching this topic have been trialled for many years. As early as 1991, Mangione et al. [2]. demonstrated that computer-assisted instruction with graphics and digitised heart sounds was just as effective as seminars at improving the identification of murmurs by students. These early studies, however, were focused on improving the understanding of cardiac auscultation in a classroom setting. The handheld echocardiogram (HHE) and digital stethoscope technique used by Leggett, on the other hand, enable students to engage with real patients whilst following a structured approach to understanding murmurs. The privilege of being able to auscultate a patient and then playback the murmur allows reinforcement of the knowledge gained from the experience. It takes a step away from the commonly heard and frustratingly vague notion that the ability to distinguish heart murmurs ‘comes with time’. Furthermore, the inability to standardise the sounds heard by teacher and student in traditional bedside teaching can cause a misinterpretation effect, where the student may alter their recollection of the sounds they heard on auscultation to fit the description of the teacher. This can lead to confusion and a lack of self-confidence in auscultation. Digital stethoscopes mitigate this effect.
Use of Anakinra in steroid dependent recurrent pericarditis: a case report and review of literature
Published in Journal of Community Hospital Internal Medicine Perspectives, 2021
Vinay Kumar Thallapally, Sonia Gupta, Sai Giridhar Gundepalli, Joseph Nahas
A 44-year-old male with a past medical history significant for gout initially presented to the primary care clinic with complaints of persistent shortness of breath with mild chest tightness after recovering from a recent upper respiratory tract infection. Physical examination revealed lungs clear to auscultation bilaterally, normal s1, s2 heart sounds with no abnormal rubs, murmurs or gallops. ECG showed normal sinus rhythm with no ST or Q wave changes. CT scan of the chest followed by an echocardiogram was done which showed a small posterior pericardial effusion. He was diagnosed with idiopathic pericarditis presenting as pericardial effusion and was started on naproxen 500 mg twice daily and colchicine 0.6 mg daily. However, he continued to have progressively worsening shortness of breath over the next two weeks and presented to the emergency department with the same. He received high-dose methylprednisolone 125 mg in the Emergency Department with rapid improvement in the symptoms. Laboratory workup revealed elevated ESR at 74 mm/hour (normal range 0–25 mm/hour) and CRP at 181 mg//L (normal range ≤9.00 mg/L). Other workup includes normal ferritin, α1-antitrypsin, IgG subclasses I, II, III, and IV. Angiotensin-converting enzyme, SPEP, antinuclear antibody, rheumatoid factor, hepatitis panel, Lyme serology, and tuberculosis screen were unremarkable. A repeat echocardiogram showed a moderate increase in the size of pericardial effusion with some evidence of thickened pericardium.
Related Knowledge Centers
- Auscultation
- Fourth Heart Sound
- Gallop Rhythm
- Heart Murmur
- Stethoscope
- Third Heart Sound
- Heart
- Heart Valve
- Sound
- Respiratory Sounds