Pediatric Cardiovascular (CVS) Examination Guide

Comprehensive Pediatric Cardiovascular Examination Guide
1. General Approach and Preparation
  • Ensure a quiet, warm, and well-lit environment
  • Have the child as calm and cooperative as possible
  • Undress the child to the waist, ensuring privacy
  • Position the child appropriately (supine, sitting, standing) based on age and examination phase
  • Have necessary equipment ready: stethoscope, sphygmomanometer with appropriate cuff sizes, measuring tape
2. Inspection

2.1 General Appearance

  • Color: Observe for cyanosis, pallor, plethora
  • Dysmorphic features: Look for syndromes associated with congenital heart defects (e.g., Down syndrome, Turner syndrome)
  • Signs of respiratory distress: Tachypnea, nasal flaring, intercostal retractions
  • Clubbing of fingers and toes

2.2 Chest and Precordium

  • Chest shape and symmetry: Look for pectus excavatum, pectus carinatum, scoliosis
  • Breathing pattern: Rate, depth, use of accessory muscles
  • Visible pulsations: Precordial activity, epigastric pulsations, neck vein pulsations
  • Scars: Indicative of previous surgeries

2.3 Extremities

  • Edema: Particularly in lower extremities and sacral area
  • Skin color and temperature: Compare upper and lower extremities

Normal Findings

  • Symmetric chest wall movement
  • No visible abnormal pulsations
  • Pink mucous membranes and nail beds
  • No edema or clubbing

Abnormal Findings and Associated Conditions

  • Central cyanosis: Cyanotic congenital heart defects
  • Visible, forceful apical impulse: Ventricular hypertrophy
  • Chest wall deformities: May be associated with Marfan syndrome or other connective tissue disorders
  • Differential cyanosis (blue lower body, pink upper body): Patent ductus arteriosus with pulmonary hypertension
3. Palpation

3.1 Technique

  1. Use fingertips to palpate precordium systematically
  2. Assess in both supine and left lateral decubitus positions
  3. Palpate all four cardiac areas: aortic, pulmonic, tricuspid, and mitral
  4. Locate and characterize the apical impulse
  5. Feel for thrills, heaves, or lifts

3.2 Specific Areas to Palpate

  • Precordium: Feel for abnormal pulsations or thrills
  • Apical impulse: Normally at 4th-5th intercostal space, mid-clavicular line
  • Liver: Assess for hepatomegaly and pulsations
  • Peripheral pulses: Radial, femoral, brachial, and dorsalis pedis

Normal Findings

  • Apical impulse: Brief tap, localized, not displaced
  • No thrills or heaves
  • Strong, equal peripheral pulses
  • No hepatomegaly

Abnormal Findings and Associated Conditions

  • Displaced apical impulse: Cardiomegaly, ventricular hypertrophy
  • Thrills: Significant valvular lesions or septal defects
  • Parasternal heave: Right ventricular hypertrophy
  • Weak femoral pulses: Coarctation of the aorta
  • Hepatomegaly with pulsations: Right heart failure
4. Auscultation

4.1 Technique

  1. Use both bell and diaphragm of the stethoscope
  2. Auscultate in supine, left lateral, and sitting positions
  3. Listen at all cardiac areas: aortic, pulmonic, tricuspid, mitral, and Erb's point
  4. Assess rate, rhythm, heart sounds, and any extra sounds or murmurs
  5. Use maneuvers to accentuate certain sounds when needed (e.g., deep inspiration, Valsalva)

4.2 Normal Heart Sounds

  • S1: "Lub" - Closure of mitral and tricuspid valves
  • S2: "Dub" - Closure of aortic and pulmonic valves
  • Normal splitting of S2 with inspiration

4.3 Abnormal Heart Sounds

  • S3: Early diastolic sound - May be normal in children and adolescents, pathological in heart failure
  • S4: Late diastolic sound - Always abnormal, indicates decreased ventricular compliance
  • Clicks: Systolic clicks may indicate valve prolapse
  • Rubs: Friction rub suggests pericarditis

4.4 Murmurs

Characterize murmurs by:

  • Timing (systolic, diastolic, continuous)
  • Grade (1-6 intensity scale)
  • Location and radiation
  • Quality (harsh, blowing, musical)
  • Duration

Normal Findings

  • Clear S1 and S2 heart sounds
  • No murmurs, clicks, or extra sounds
  • Normal rate and rhythm for age

Abnormal Findings and Associated Conditions

  • Systolic murmur: VSD, ASD, pulmonary stenosis
  • Diastolic murmur: Aortic regurgitation, mitral stenosis
  • Continuous murmur: Patent ductus arteriosus
  • Wide fixed splitting of S2: ASD
  • Single S2: Pulmonary hypertension, aortic atresia
5. Blood Pressure Measurement

5.1 Technique

  1. Use appropriate cuff size (bladder width 40% of arm circumference, length 80-100% of arm circumference)
  2. Measure in both arms and a leg (right arm, left arm, right leg)
  3. Child should be calm and in a seated position with back supported
  4. Take multiple readings and average them

Normal Findings

  • BP varies with age, height, and gender
  • Generally, systolic BP less than 90th percentile for age, sex, and height
  • Diastolic BP less than 90th percentile for age, sex, and height
  • Leg systolic BP should be equal to or slightly higher than arm BP

Abnormal Findings and Associated Conditions

  • Hypertension: BP consistently above 95th percentile for age, sex, and height
  • Significant difference between arm and leg BP (>20 mmHg): Suspect coarctation of the aorta
  • Large difference between right and left arm BP (>10 mmHg): Suspect aortic arch anomalies
6. Additional Assessments

6.1 Pulse Oximetry

  • Measure oxygen saturation in right hand and either foot
  • Normal: >95% in both limbs, with less than 3% difference
  • Abnormal: Lower saturation or >3% difference may indicate cyanotic heart disease or PDA with pulmonary hypertension

6.2 Hepatojugular Reflux Test

  • Apply pressure over the liver for 10 seconds while observing jugular veins
  • Positive test (sustained jugular vein distension) suggests right heart failure

6.3 Assessment of Peripheral Edema

  • Check for pitting edema in lower extremities and sacral area
  • Presence of edema may indicate heart failure or other systemic conditions
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