CVS complaints in children most commonly due to congenital heart disease (acquired heart disease is less common in paediatric patients)

Examination of

• Peripheral pulses
• Praecordium
• Chest abdomen

Percussion of praecordium for assessment of heart size is unnecessary

Growth assessment and nutritional status

• Physical growth of child suspected to have heart disease as FTT is a frequent manifestation of heart failure
• Wt, ht, head circumference appropriate for age? Measure and plot onto standard growth chart for serial monitoring against percentiles
• Wt percentiles usually drops before ht and head circumference percentiles
• Chronic uncontrolled heart failure, ht also falls though head usually spared

Dysmorphic features

Cyanosis

• Central vs. peripheral
• Central: hypoxaemia, resp disease, congenital cyanotic heart disease, conjunctiva congested due to secondary polycythaemia, blue tongue
• If blue only on extremities - peripheral cyanosis - due to VC secondary to hypothermia or low CO

Fluid retention

• CHF
• Pitting oedema not common in infants with heart failure; periorbital puffiness may be present

Pulse inspection of upper limb

Femoral arterial pulse of LL

• Compare vol. of UL with that of LL
• Weak or absent femoral pulse in presence of strong UL pulse - coarctation of aorta
• Radial-femoral pulse delay - aortic coarctation (undetectable in children)
• If all pulses weak, systemic hypotension secondary to low CO, stenosis

Expose praecordium and chest

• Signs of resp distress
• Praecordial bulging
• Cardiac pulsation
• Harrison sulcus
• Surgical scars

Resp distress

• Tachypnoea
• Subcostal and suprasternal insucking
• Use of accessory resp muscles
• Due to pulmonary arterial and venous congestion due to increase pul BF and decreased ventricular compliance

Praecordial bulging

Cardiomegaly (most prominent when RV dilated)

Mild sternotomy scar - previous open heart surgery

Thoracotomy scar

• Systemic pulmonary arterial shunting repair of aortic coarctation
• May be missed if not exposed adequately

Visible cardiac pulsation

• Pressure overload of R or LV (depending on site of pulsation)

Harrison sulcus

• Pulmonary vascular congestion or COPD
• Repetitive contraction of diaphragmatic attachment to ribcage

• Apex
• Strong cardiac impulses
• Thrills
• Suprasternal pulsation

Apex localisation

• Lowest and outmost pt of distinct cardiac pulsation
• Children: use tips of index and middle fingers
• Normally in 4th IC (infants) 5th IC in older children at or medial to MCL

Character of apical impulse: if strong apical impulse

• Press palm firmly over praecordium just to left of sternum

Strong left parasternal impulse (RV impulse)

1. Press loading of RV: pul stenosis, pul HT
2. Vol-loading of RV: atrial septal defect, pul regurgitation

Thrills

Palpable murmur

• Sought over praecordium, suprasternal region and carotid arteries
• Note location and timing in relation to cardiac cycle

Suprasternal pulsation / thrills

• Aortic stenosis
• Pul stenosis
• Coarctation of aorta
• Patent DA

Stethoscope

• Diaphragm: high pitch and murmur (eg. Blowing diastole murmur in aortic regurgitation)
• Bell: low pitch, heart murmur (mitral stenosis, low rumbling)
• Start at 4 cardinal auscultation areas with diaphragm

Cardinal areas of auscultation

• Mitral - apex beat
• Tricuspid - at left lower sternal border
• Pulmonary area - left of sternum in 2nd IC
• Aortic area - right of sternum in 2nd IC space

Sounds and murmurs heard in a an area may not be from that area

Eg. Murmurs from aortic valves best audible at apex and left lower sternal border

Heart sounds

Added sounds

• Ejection click: opening of stenotic pul or aortic valve during systole
• Opening snap; stenotic mitral valve ring diastole

Cardiac murmurs: turbulence in blood flow

• Intensity
• Timing
• Location
• Radiation
• Quality

Place stetho over aorta

• Systolic murmur aortic in origin

Murmur sought from posterior chest wall

• Stenotic branched pulmonary arteries radiate to back
• Soft pulmonary collateral murmurs better heard from back

Place bell at cardiac apex with Pt turning toward left side (mitral stenotic - rumbling low pitch murmur)

Chest Examination

• Signs of resp distress
• Crepitations due to pulmonary oedema

Need to examine abdomen as well

Hepatomegaly: systemic venous congestion (cardinal sign)

• Lower edge: palpation
• Upper edge: percussion
• Left or central: may be associated complex cyanotic congenital heart disease

Measure of BP

• End of CV examination in children (discomfort)
• Use cuff appropriate to size of child's right upper arm
• Cubital fossa at heart level
• Size = bladder 40% of arm circumference midway bet olecranon and acromion (covers 80% (?) of circumference of arm)
• Palpate radial artery while inflating cuff to ensure 20-30 mmHg above press needed to obliterate pulse
• BP: 5th Korotcoff sounds or disappearance

• Practice makes perfect
• Do not rely solely on cardiac murmurs for making cardiac diagnosis
• Inspection, palpation and auscultation are equally important