Part II Examination of the Newborn and Older Child
4 Examination of the Older Child
4.9 Cardiovascular System Examination
4.9.2 Examination of the Precordium
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Significant cervical lymphadenopathy may occur in certain conditions with cardiac involvement (e.g., Kawasaki disease).
– Trachea
Palpate the trachea and look for any deviation.
• Capillary refill
– Apply blanching pressure with a finger or thumb on the skin of the child’s sternum (or a digit at the heart level) for 5 s, then release and watch for the color to return. Blush normally takes less than 2 s to return; if it takes longer, then poor peripheral perfusion or shock should be suspected [21].
• Abdomen
– Palpate and percuss the abdomen for hepatosplenomegaly; this may be a late sign of heart failure. The liver may be pushed downward in some respiratory conditions (e.g., bronchiolitis, pleural effusion, empyema, emphysema, etc.).
Therefore, measurement of the liver span is very important to differentiate an enlarged liver from a pushed-down liver.
– Enlargement of the spleen alone may occur in infective endocarditis.
– Examine for ascites if heart failure is suspected.
• Back and lower limbs
– Examine for edema (ankle, sacrum, and precordium).
Pitting peripheral edema is a late manifestation of congestive heart failure in children [36].
In infants, edema is usually seen periorbital and over the flanks, while in older children pedal edema occurs as well.
– Examine for arthritis and look for joint swelling and skeletal deformities, which may point to syndromes or diseases that are associated with cardiac conditions (e.g., Marfan syndrome, systemic lupus erythematosus (SLE), or rheumatoid arthritis).
• Nervous system
– Note any involuntary movements and focal deficits.
• Nutritional status assessment and anthropometric measures
– Both heart failure and cyanotic congenital heart disease can lead to a failure to thrive. Hence, assessment of the nutritional status of the child, along with measurement of his/her growth parameters and plotting the readings on stan-dard percentile growth charts, is very important [39].
– Asymmetry
While the child is lying supine, inspect for asymmetry from the child’s feet on the same plane as his/her chest. A left precordial bulge may indicate car-diomegaly [37].
– Visible ventricular impulse
The left ventricular impulse (apex beat) can be seen in thin children or those with hyperdynamic circulation (e.g., excitement or fever), and it is also seen in left ventricular enlargement.
– Hyperdynamic precordium
A hyperdynamic precordium may be normal in a thin child, or it may suggest a volume load (as in a large left-to-right shunt) [39].
– Dilated veins over chest wall
• Palpation – Apex beat
Palpate for the apex beat with a flat hand or with the pulp of two fingers.
In children aged less than 4 years, palpate for the apex beat at the fourth inter-costal space, slightly outside or at the left mid-clavicular line (a vertical imaginary line passes through the midpoint of the clavicle.) In children between 4 and 7 years, the apex beat is located in the fourth or fifth inter-costal space at or slightly medial to the left mid-clavicular line.
In certain circumstances, the apex beat may be displaced from its normal place to the left (e.g., cardiomegaly) or to the right (e.g., congenital dextrocardia).
Assess the character of the apex beat, as it may provide a vital diagnostic clue.
For example:
Sustained suggests pressure overload (e.g., aortic stenosis).
Forceful indicates left ventricular hypertrophy.
Thrusting points to volume overload (e.g., left-to-right shunt, mitral or aortic regurgitation).
Tapping may occur in mitral stenosis.
The apex beat may be absent in obese children or those with a hyperinflated chest, as well as in those who have pericardial effusion. Dextrocardia should also be considered.
– Heaves
A heave is a palpable impulse that prominently lifts your hand.
Palpate for the left parasternal heave by placing the palm or the ulnar border of your right hand firmly over the left parasternal area. A presence of heave suggests right ventricular hypertrophy [37].
– Thrills
A thrill is a palpable murmur. Palpate for thrills with the flat of your hand over the apex, lower-left sternal edge (ventricular septal defect), upper-left sternal edge (pulmonary stenosis), upper-right sternal edge, and in the suprasternal notch (aortic stenosis or coarctation of the aorta).
– Palpable heart sounds
A palpable second heart sound may indicate pulmonary hypertension.
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• Percussion
– Percussion is inaccurate for assessing heart size in children, but it may be use-ful in detecting a mediastinal shift.
• Auscultation
– The child should be quiet during the auscultation.
– Use both the bell and the diaphragm of your stethoscope to listen carefully over the four valve areas (see Fig. 4.13):
Apex
Lower-left sternal edge (tricuspid area)
Table 4.8 Types of pathological murmurs in common heart diseases [28, 35–37, 39]
Lesion Type of murmur Best site to be heard Radiation Aortic stenosis Ejection systolic Aortic area (right second
intercostal space)
Toward upper-right sternal edge, over carotids
Pulmonary stenosis Ejection systolic Pulmonary area (left second intercostal space)
To left side of the neck or beneath left scapula
Atrial septal defect (ASD)
Ejection systolic with a wide, fixed splitting of the second heart sound
Pulmonary area To right axilla
Aortic incompetence
Early diastolic Upper and mid-left sternal border (best heard while the child is sitting and holding on expiration)
Down left sternal edge toward apex, left axilla Pulmonary
incompetence
Early diastolic Left sternal border Mitral stenosis
(rare)
Mid-diastolic Apex Tricuspid stenosis Mid-diastolic Apex Mitral
incompetence
Pansystolic Apex To left axilla or
beneath left scapula Tricuspid
incompetence
Pansystolic Lower-left sternal border To epigastrium or to lower-right sternal border
Ventricular septal defect (VSD)
Pansystolic with mid-diastolic (if large)
Lower-left sternal border (fourth intercostal space)
All over pericardium
Mitral valve prolapse
Late systolic Apex Patent ductus
arteriosus (PDA)
Continuous Left second intercostal space
To back and left clavicle Coarctation of the
aorta
Systolic or continuous
Left sternal border To left infrascapular area and
occasionally to the neck
4 Examination of the Older Child
Upper-left sternal edge (pulmonary area) Upper-right sternal edge (aortic area)
– If you heard a murmur over any of these areas, listen over the site of radiation (see Table 4.8).
– Do not forget to auscultate over the back for patent ductus arteriosus (PDA), pulmonary stenosis (PS), and coarctation of the aorta.
– Auscultate with the child in both lying and sitting positions, and concentrate on the following:
Heart Sounds
• First heart sound
– The first heart sound results from the closure of mitral and tricuspid valves.
– A loud first heart sound is heard in:
Atrial septal defect (ASD) Mechanical prosthetic valve Mitral stenosis (rarely)
• Second heart sound
– The second heart sound results from closure of aortic and pulmonary valves.
– A loud second heart sound is heard in:
Conditions that lead to increased pulmonary flow, such as patent ductus arteriosus (PDA), atrial septal defect (ASD), and large ventricular septal defect (VSD) Pulmonary hypertension
– It is important to note any changes in heart sounds with breathing. Splitting of the second heart sound may normally occur with respiration, but a wide fixed (i.e., invariable with breathing) splitting may point to an atrial septal defect (ASD).
Added Sounds
• Third heart sound
– A low-pitched sound may be heard early in diastole after the second heart sound. It is best heard with the bell of the stethoscope at the apex.
– It is normally heard in healthy infants and younger children, but it can also be heard in heart failure.
• Fourth heart sound
– A fourth heart sound may be heard just before the first heart sound.
– It is always pathological and may indicate pulmonary hypertension or heart failure.
• Opening snap
– An opening snap is a high-pitched sound that may be heard after the second heart sound and may point to mitral stenosis.
• Ejection click
– An ejection click is a high-pitched sound that may be heard early in systole after the first heart sound and may indicate aortic or pulmonary stenosis.
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Murmurs
• Murmurs are sounds caused by the turbulence of blood flow. They may be inno-cent or pathological.
• If you hear a murmur, check for the following:
– Timing: systolic, diastolic, or continuous Diastolic murmurs are always pathological.
– Duration: early diastolic, late systolic, pansystolic, etc.
– Grading of murmurs:
Grade I—barely audible Grade II—medium intensity
Grade III—easily heard, but no thrill Grade IV—loud with a thrill
Grade V—very loud with a thrill, often heard over a wide area
Grade VI—extremely loud with a thrill. It can be heard even without a stethoscope
– Pitch: low-pitched murmurs may be caused by a large opening, a low-pres-sure gradient, or both, while high-pitched murmurs may result from a small opening, a high-pressure gradient, or both.
– Quality: blowing, harsh, musical, or rumbling.
– Site of maximum intensity and radiation (see Table 4.8).
Normal Murmurs (Innocent)
• Normal murmurs are common in children, due to increased blood flow velocity.
They can be distinguished from pathological murmurs by the fact that they are usually systolic, soft, and short, with a musical quality, without radiation, and symptom-free, with no abnormal signs or tests.
Pathological Murmurs (See Table 4.8)
• These are generally of high grades (≥3), with a harsh quality; they may radiate to other sites and may be symptomatic and associated with abnormal signs and tests. They can be classified as:
– Systolic murmurs – Diastolic murmurs – Continuous murmurs
• Grades I and II are usually innocent murmurs. Grades V and VI are always significant.
Notes 4.9
4 Examination of the Older Child