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Cardiovascular System Examination in Pediatrics: A Comprehensive Guide, Slides of Pediatrics

University of Kerbala (UK)Pediatrics

A detailed guide on performing a cardiovascular system examination in pediatrics. It covers acute assessment, taking a thorough history, general exam, inspection, peripheral palpation, precordium palpation, and auscultation. The document emphasizes the importance of considering the child's age, development, and disposition during the exam.

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2021/2022

Uploaded on 09/07/2022

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Cardiac Examination
Learnpediatrics.com Narration
Written by Dr. J. Bishop
Introduction
Welcome to the LearnPediatrics examination of the cardiovascular system. A
standardized approach to the physical exam will be presented here but as with all
pediatric exams, it is important to be flexible and to take advantage of the opportunity
to perform different parts of the exam as they present themselves. As you go through
your exam be sure to keep in mind the child’s age, development and disposition and
to interpret findings accordingly.
Acute Assessment
Your evaluation begins with the acute assessment of the child. This information
allows you to dictate the pace and thoroughness of the exam. Begin with an
assessment of the ABC’s. If the child is unwell it may be necessary to address acute
problems prior to obtaining a history and physical.
Observe the child for any signs of distress. These may include pallor, sweating,
cyanosis or increased work of breathing. Observe the level of activity in the patient.
Do they appear comfortable? Are they interacting in an appropriate manner with you
and their parent?
History
A well taken pediatric history is an essential beginning to a cardiovascular
assessment. Begin with the general health of the child including feeding difficulties,
growth delay and decreased exercise tolerance. In the older child, asking the parent
to compare the child to peers of the same age can help in this assessment.
Specific symptoms that can indicate cardiovascular disease can include periods of
cyanosis, sweating, shortness of breath, palpitations and edema. Chest pain and
syncope, while relatively rare in the pediatric population may indicate underlying
cardiac pathology. Squatting after exercise can indicate congenital cardiac defect
such as Tetralogy of Fallot. Be sure to enquire about the prenatal period. Exposure
to medication or drugs such as lithium, phenytoin and alcohol can be associated with
cardiac lesions. History of maternal illnesses such as Systemic Lupus
Erythematosus, Diabetes or primary rubella should be elicited. Children that were
born prematurely are at an increased risk of having a patent ductus arteriosus.
Don’t forget the family history. This often reveals the presence of other family
members with congenital heart defects or early onset cardiovascular disease. This
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Cardiac Examination

Learnpediatrics.com Narration Written by Dr. J. Bishop

Introduction

Welcome to the LearnPediatrics examination of the cardiovascular system. A standardized approach to the physical exam will be presented here but as with all pediatric exams, it is important to be flexible and to take advantage of the opportunity to perform different parts of the exam as they present themselves. As you go through your exam be sure to keep in mind the child’s age, development and disposition and to interpret findings accordingly.

Acute Assessment

Your evaluation begins with the acute assessment of the child. This information allows you to dictate the pace and thoroughness of the exam. Begin with an assessment of the ABC’s. If the child is unwell it may be necessary to address acute problems prior to obtaining a history and physical. Observe the child for any signs of distress. These may include pallor, sweating, cyanosis or increased work of breathing. Observe the level of activity in the patient. Do they appear comfortable? Are they interacting in an appropriate manner with you and their parent?

History

A well taken pediatric history is an essential beginning to a cardiovascular assessment. Begin with the general health of the child including feeding difficulties, growth delay and decreased exercise tolerance. In the older child, asking the parent to compare the child to peers of the same age can help in this assessment. Specific symptoms that can indicate cardiovascular disease can include periods of cyanosis, sweating, shortness of breath, palpitations and edema. Chest pain and syncope, while relatively rare in the pediatric population may indicate underlying cardiac pathology. Squatting after exercise can indicate congenital cardiac defect such as Tetralogy of Fallot. Be sure to enquire about the prenatal period. Exposure to medication or drugs such as lithium, phenytoin and alcohol can be associated with cardiac lesions. History of maternal illnesses such as Systemic Lupus Erythematosus, Diabetes or primary rubella should be elicited. Children that were born prematurely are at an increased risk of having a patent ductus arteriosus. Don’t forget the family history. This often reveals the presence of other family members with congenital heart defects or early onset cardiovascular disease. This

should include parents, grandparents, aunts, uncles and cousins. Always ask this question of the parents: Are you related to each other? In pediatrics you will encounter children of different ages and different stages of development. Be cognicent of every individual child’s need for privacy and provide them with adequate covering during the exam.

General exam

Before starting any physical exam ensure that your hands are properly washed. Observe the body habitus, noting any dysmorphic features that may indicate a syndrome associated with congenital heart disease. Common examples would include Trisomy 21, Di George and Turner’s syndrome. You should take a complete set of vital signs including heart rate, respiratory rate, blood pressure, height, weight, and for children under 5 years of age, head circumference. If the heart rate is regular, count the beats over 15 seconds and multiply by 4. Ideally, the blood pressure should be taken in all four limbs. Choosing the proper cuff size is extremely important but even more so is the size of the cuff bladder. Use of a cuff that is too small will provide a falsely high blood pressure reading. The cuff bladder should be wide enough to cover between 40 and 75% of the upper arm and should be long enough to completely encircle the arm and be properly closed. Be sure to plot the growth on an age appropriate chart. What can be of particular help is having growth measurements at several ages plotted on the same chart.

Inspection

Examine the hands and feet. Note the presence of clubbing, splinter hemorrhages or any other abnormalities of the nails. Assess for clubbing by asking the child to hold the two index fingers together and looking at Lovibond’s angle. Check the capillary refill. A normal refill is less than 2 seconds. Cardiac abnormalities normally manifests as respiratory distress. Look for signs of increased work of breathing such as tachypnea, intercostal indrawing, tracheal tug, head bobbing and nasal flaring. Abdominal breathing is normal in the neonate but not in the older child. Turn your attention to the child’s face. Look at the eyes for scleral icterus or pallor. Next look inside the mouth for signs of central cyanosis. Examine the mucous membranes to assess the volume status of the patient. Assessment of the jugular venous pressure is not routinely performed in the pediatric patient under 8 years of age. Although, it is applicable to older adolescent and young adult patients.

Auscultation

Before beginning, let’s review the areas of cardiac auscultation. Each of these spaces has a traditional valvular name but it is important to remember that murmurs of more than one origin may be heard in a given area. The first area is the 2 nd right interspace next to the sternum - this is the aortic area. The 2 nd intercostal space to the left of the sternum is described as the pulmonic area. The lower left sternal border is known as the tricuspid area, and the apex is described as the mitral area. Be sure to listen to the back. The murmur of aortic coarctation is sometimes only found here and will be missed if not specifically listened for. Listen at each of these spaces with both the bell and the diaphragm of the stethoscope. The diaphragm picks up high pitched sounds such as pericardial rubs, S1 and S2, as well as most murmurs. The bell placed lightly on the chest works best for hearing low pitched sounds such as a gallop or for best hearing the S2 split. The S2 should be widest split at the end of inspiration. Hearing and interpreting all of these sounds takes significant time and practice in pediatrics. Go slowly and listen carefully. If a murmur is heard, listen for the timing in the cardiac cycle, volume (configuration) and radiation. Determine at which area the murmur is loudest and then listen for radiation at all of the other areas, including both the axilla and the back. Remember that more than 50% of children will have a murmur at some point while congenital heart disease is present in less than 1%. Learning to distinguish pathologic from benign murmurs is extremely important and takes practice. Lastly, listen to the lungs. If there are crepitations this may be a late sign of pulmonary congestion secondary to congestive heart failure.

Conclusion

This concludes the cardiac examination in the pediatric patient. Remember that like with all physical exams, becoming competent at the cardiac evaluation takes time. Be sure to do a systemic exam in all patients with a good focus on the general health status of the child. If you think there is cardiac pathology refer to a cardiologist for further evaluation.