CVS examination in detail given in paper

Details of examination of cvs system

1. CARDIOVASCULAR SYSTEM SYSTEMIC EXAMINATION DR. YASH SONAGRA GUIDE- DR. ABOLI DAHAT

2. Different anatomical lines

3. A cardiovascular examination should start with careful inspection of child by asking a few questions. Is the child breathless? - pulmonary vascular engorgement, usually caused by heart failure. Is the child cyanotic? Is the child dysmorphic? ( Trisomy 21- VSD, AVSD, PDA; Turner- Coarctation, aortic stenosis, ASD (in 35%). Does the child have any thoracic scars?

4. EXAMINATION OF THE PRECORDIUM Precordium refers to the anterior chest wall area overlying the heart. The heart is normally positioned beneath the sternum and to the left of the sternum. Its apex is usually located just inside of the midclavicular line in the 5th left intercostal space.

5. INSPECTION OF PRECORDIUM 1. Precordium- S ymmetry and shape of the anterior chest wall Precordial chest deformities - Pectus carinatum, pectus excavatum P recordial bulge

6. APICAL IMPULSE Refers to the outermost and lowermost definitive outward thrust of cardiac impulse in lower precordium. Note the location and character of apical impulse. Also look for abnormal pulsations in the following areas: ( i ) left parasternal (ii) epigastric (iii) suprasternal (iv) localized pulsation in the pulmonary area—second left intercostal space (v) both sides of the neck and also over the back of the chest (vi) right parasternal and intercostal spaces in conditions of dextrocardia, dextroposition, or marked cardiac enlargement.

7. PALPATION The clinical objectives of palpation over the precordium are to localize, characterize, record, and interpret from the characteristics of: A pex beat (or point of maximal impulse) P recordial pulsations over specified areas Heaves and thrusts Palpable sounds T hrills.

8. APEX BEAT The apex beat is defined as the lowest and most lateral point at which the cardiac impulse can be palpated. Location- BIRTH TILL 1 YEAR 3rd left intercostal space 0.5—1 cm lateral to the midclavicular line 1- 4 YEARS 4th left intercostal space mostly just lateral to the mid-clavicular line and occasionally in the 5th left intercostal space. 4- 8 YEARS 4th (mostly) or 5th left intercostal space in the midclavicular line . 8- 12 YEARS 4th or 5th left intercostal space 1 cm medial to the mid-clavicular line . 12 YEARS AND BEYOND 5th left inter costal space l cm medial to the mid-clavicular line .

9. Types of Apical impulse Heaving- Diffuse, slow rising impulse and well sustained. Usually associated with pressure overload. Tapping- Well localized, sharp rising and ill sustained. Associated with volume overload. Hyperdynamic- suggest a volume overload state found in large left to right shunt.

10. APEX IMPULSE Absent/Feeble Hyperdynamic Heaving Tapping -Dextrocardia -Behind a rib - Obesity - Pericardial effusion - High cardiac output states - Pectus excavatum - Thin chest wall Aortic regurgitation Mitral regurgitation Ventricular septal defect A-V fistula -Aortic stenosis - Hypertrophic cardiomyopathy - Severe left ventricular dysfunction

11. Precordial pulsations Systolic pulsation in pulmonary area: Palpate by placing the pad of the index finger in the 2nd left intercostal space just lateral to the sternal border in the pulmonary area. Systolic pulsations indicate pulmonary arterial dilatation. Suprasternal pulsations: present in aortic regurgitation (AR), patent ductus arteriosus (PDA), coarctation of aorta, aortic aneurysm. Epigastric pulsations: are suggestive of right ventricular volume overload states- including atrial septal defect, tricuspid regurgitation, and moderate to large ventricular septal defect.

12. Parasternal pulsations- Parasternal pulsations without lift maybe felt in very thin children with muscle wasting. Pulsations in the parasternal area without a perceptible or palpable left parasternal lift is characteristic of right ventricular volume overload conditions like ASD, TR, moderate to large VSD without pulmonary arterial hypertension, besides hyperdynamic high output states. Pulsations along the right sternal edge are characteristic of large right atrium as in Ebstein anomaly.

13. Parasternal Heave Grade 1 : Noticeable left parasternal pulsatile impulse in the left intercostal spaces with mild upward lift, seen by placing a pencil or ballpoint pen over that area. Seen in right ventricular enlargement . Grade 2: Forward obvious forceful left parasternal lif t obliterated by firm pressure by fingers or ulnar side of the palm. Caused by mild right ventricular hypertrophy . Grade 3: Outward forceful and sustained left parasternal lift not obliterated by firm pressure by ulnar side of the palm. Suggests significant right ventricular hypertrophy .

14. Other Palpable Sounds Palpable first sound (S1) over the apex- Mitral stenosis (felt as tapping apex). Palpable second sound (S2) in pulmonary area- Pulmonary hypertension. Palpable third sound (S3)- Severe MR or dilated cardiomyopathy. Opening snap- in the early diastolic period may sometimes be felt in mitral stenosis. Systolic ejection clicks- palpable in severe pulmonary hypertension. Pericardial knock May be felt in constrictive pericarditis.

15. Thrills E quivalents of the vibrations of murmurs heard in that particular area. Time the thrill in relation to the cardiac cycle as: -systolic - diastolic - continuous.

16. Percussion Step 1: Delineate the Upper Border of the Liver Step 2: Define the Right Heart Border Step 3: Delineate the Left Heart Border

17. The right heart border lies within 1 cm lateral to the right border of the sternum. The right heart border is formed from above downwards by superior vena cava, right atrium, and inferior vena cava. The left heart border is formed from above downwards by arch and descending aorta, pulmonary artery, left atrial appendage, and the left ventricle.

18. Percussion Findings and Interpretations Extension of dullness beyond the right sternal border indicates right atrial enlargement. Dullness beyond the apical impulse on the left side indicates pericardial effusion. Dullness > 2.5 cm beyond left sternal border in the second left intercostal space indicates pulmonary arterial hypertension, patent ductus arteriosus (PDA), left atrial enlargement, aortic aneurysm

19. Auscultation To identify abnormal additional sounds and murmurs T o distinguish normal sounds and innocent murmurs from abnormal sounds T o characterize pathological murmurs based on - loudness -quality -location -timing

20. Areas for Auscultation: Other areas- Both carotids Both interscapular Region 3. Over femorals , brachial arteries

21. First heart sound (S1) P roduced by closure of tricuspid and mitral valves, is usually heard as a single sound. Best heard at apex. Abnormalities of intensities of first heart sound Quiet Low cardiac output Poor left ventricular function Long P-R interval (first degree heart block) Loud Mitral stenosis Increased cardiac output Variable Atrial fibrillations

22. Second heart sound (S2) Second heart sound is produced because of closure of semilunar valves of aorta and pulmonary artery. It has two components - the first component (A2) is by aortic valve closure and the second (P2) is caused by closure of the pulmonic valve.

23. Third Heart Sound (S 3) H eard with the bell, during the rapid ventricular filling phase. -It can Physiological or Pathological. Fourth Heart Sound (S4) It occurs in the late diastolic period due to atrial contraction against ventricular noncompliance or left ventricular resistance to left atrial blood flow across mitral valve. It is almost always pathological. Left atrial S4 gallop: Aortic valvular stenosis, systemic arterial hypertension. Right atrial S4 gallop: Pulmonary arterial hypertension, pulmonary stenosis, ASD.

24. Gallop Rhythms- a gallop rhythm is attributed to poor ventricular function Triple rhythm : S3 gallop/ventricular or early diastolic gallop: S1, S2 and S3 heard in tachycardia. S4 gallop / atrial or presystolic gallop: S1 + S2 + S4 (forceful atrial contraction sound) Quadruple rhythm : All the four heart sounds are heard in presence of tachycardia. Summation gallop : Marked tachycardia shortens the diastolic interval; and both S3 and S4 are heard together because of their closeness to each other.

25. CARDIAC MURMURS Characteristics of Murmurs Site of origin Phase and timing Duration (length) I ntensity-amplitude or loudness Frequency Shape or configuration Conduction and radiation Tonal quality Dynamic variation

26. GRADE DESCRIPTION GRADE 1 Barely audible, faint GRADE 2 Faint, but clearly audible GRADE 3 Moderately loud without palpable thrill GRADE 4 Loud with a thrill GRADE 5 Very loud, thrill present, and audible even with the edge or rim of the diaphragm of the stethoscope touching the chest wall area where thrill is felt GRADE 6 Very loud, heard with the stethoscope lifted off the chest wall by a few mm. GRADING OF SYSTOLIC MURMURS

27. GRADING OF DIASTOLIC MURMURS GRADE DESCRIPTION GRADE 1 Very soft/faint murmur GRADE 2 Faint but heard easily without difficulty GRADE 3 Loud without a palpable thrill GRADE 4 Loud with a thrill

28. Pathological Murmurs Characteristics of Pathologic Murmurs A murmur with the following characteristics is NEVER considered INNOCENT All pansystolic murmurs All diastolic murmurs Late systolic murmurs Loud murmurs: 3/6—6/6 (very loud murmur with and without thrill) Continuous murmurs (except venous hum) Murmurs with abnormal cardiac findings

29. Innocent Murmurs Also called as functional murmurs, arise from cardiovascular structures in the absence of anatomical abnormalities.. Classic vibratory murmur- most common innocent murmur. Has a distinctive quality described as ‘twanging string’. Pulmonary ejection murmur. Pulmonary flow murmur of newborns Venous hum Carotid bruit

30. ORGANIC MURMURS SYSTOLIC MURMURS DESPCRIPTION Aortic Stenosis Crescendo-decrescendo systolic ejection murmur (ejection click may be present). Loudest at heart base; radiates to carotids. Mitral/tricuspid regurgitation Holosystolic, high-pitched “blowing murmur.” Mitral—loudest at apex and radiates toward axilla. Tricuspid—loudest at tricuspid area. Mitral valve prolapse Late systolic crescendo murmur with mid-systolic click (due to sudden tensing of chordae tendineae). Most frequent valvular lesion. Best heard over apex. Ventricular septal defect Holosystolic, harsh-sounding murmur. Loudest at tricuspid area.

31. DIASTOLIC MURMURS DESCRIPTION Aortic/Pulmonary regurgitation High-pitched “blowing” early diastolic decrescendo murmur. Often due to aortic root dilation, bicuspid aortic valve, endocarditis, rheumatic fever. Mitral/Tricuspid stenosis Delayed rumbling mid-to-late diastolic murmur, follows opening snap CONTINUOUS MURMURS DESCRIPTION Patent ductus arteriosus Continuous machine-like murmur. Loudest at S2. Often due to prematurity. Best heard at left infraclavicular area.

32. BEDSIDE MANOEUVRE TO BEDSIDE MANOEUVRE EFFECT Inspiration (increase venous return to right atrium) Increase intensity of right heart sounds Hand grip (increase afterload) Increase intensity of MR, AR, and VSD murmurs Increase hypertrophic cardiomyopathy and AS murmurs MVP: later onset of click/murmur

33. Valsalva (phase II), standing up (reduce preload) Increase intensity of most murmurs (including AS) Increase intensity of hypertrophic cardiomyopathy murmur. MVP: earlier onset of click/murmur Rapid squatting (increase venous return, increase preload, increase afterload) Increase intensity of hypertrophic cardiomyopathy murmur Increase intensity of AS, MR, and VSD murmurs MVP: later onset of click/murmur

34. Finishing the cardiovascular examination examination of the abdomen for organomegaly & abdominal aortic aneurysm. auscultation of the chest bases for crackles

35. References Glynn M Drake WM Hutchison R.  Hutchison's Clinical Methods : An Integrated Approach to Clinical Practice . 23rd ed. Edinburgh: Elsevier; 2012. Behrman RE.  Nelson Textbook of Pediatrics / Richard E. Behrman [and Three Others] Editors.  Twenty-one edition. (Behrman RE, ed.). Elsevier; 2020. Le, Tao; Bhushan, Vikas; and Sochat , Matthew.  First Aid for the USMLE Step 1 2021. New York: McGraw-Hill Education, 2021. Gupta P., Clinical methods in pediatrics , 5 th edition, CBS publishers & distributors.

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