cvs examination in paediatrics

various headings under which cvs examination to be done.

1. CARDIOVASCULAR SYSTEM EXAMINATION

INSPECTION:



1. SHAPE AND SYMMETRY OF CHEST WALL:
NORMAL: bilaterally symmetrical, antero posterior diameter to transverse diameter - 5:7

2. CHEST DEFORMITIES:
-Funnel shaped chest: Marfans syndrome.
-pigeon shaped chest: Rickets.

3. PRECORDIAL BULGE:
-Chronic cardiomegaly.

4. TRACHEAL POSITION :
-Central/ shifted

5. APICAL IMPULSE:
-4
TH
intercostal space, just lateral to the midclavicular line.

6. OTHER VISIBLE PULSATIONS:
- Aortic area, pulmonary area, epigastric region, suprasternal area, carotid area.

7. DILATED VEINS, SCARS and SINUSES.

2. PALPATION

1. JUGULAR VENOUS PULSE (JVP):
-Keep the patient at 45 degree .
-Turn head to left side.
-Draw transverse line over the upper border of oscillatory column in the internal jugular vein and at the level
of Sternal angle.
-Using cm ruler , vertical distance between both horizontal line measure JVP.
-If distance >3cm (JVP elevated).
-5cm is added to obtain an estimate of mean right atrial pressure in cms of blood.

-Causes for raised JVP: right ventricular failure, tricuspid stenosis or regurgitation, pericardial effusion, fluid
overload.


2.APEX BEAT:
PROCEDURE: Start by doing this with entire hand, gradually become more specific until it is felt under one finger.
*palpating with hand.
*locating with finger.
*best studied in left lateral position of the patient.

a) LOCATION: 4
th
intercostal space just lateral to mid-clavicular line.
Cause for shift in apex beat : Left or right ventricular hypertrophy, Dextrocardia.

b) CHARACTER:
TAPPING APEX BEAT- mitral stenosis (slight increase in amplitude).
HYPERDYNAMIC APEX BEAT: systemic hypertension, aortic stenosis, volume overload.
HEAVING APEX BEAT: (both amplitude and duration is increased).aortic regurgitation, vsd.
DIFFUSE APEX BEAT: left ventricular aneurysms.
DOUBLE APICAL IMPULSE: aortic stenosis or regurgitation.
TRIPLE OR QUADRUPLE APEX BEAT: HOCM.

3. ABSENT APEX BEAT: obese children ,impulse behind the rib


3.TRACHEAL POSITION :
TRAIL’S SIGN: t is the undue prominence of the clavicular head of sternomastoid on the side to which trachea is
deviated.

4 .PARA STERNAL HEAVE: Palpable thrust which lifts the hand in parasternal region.
 Palpated by ulnar aspect of palm.
 Also can be demonstrated by placing a pen on the left parasternal region, which will move perpendicular
to chest wall.
 Seen in right ventricular enlargement, left atrial enlargement.
GRADING OF PARASTERNAL IMPULSE (AIIMS grading):
GRADE 1: visible but not palpable.
GRADE 2: visible and palpable but obliterable.
GRADE 3: visible and palpable but not obliterable.

5. THRILLS/PALPABLE MURMURS:
These accompany any organic murmur of GRADE 3 or more.
TYPES: Aortic thrills, Pulmonary thrills, Left lower parasternal thrills, Apical thrills.
TIMING: systolic thrills, diastolic thrills, continuous thrills.



PERCUSSION:


BORDERS OF HEART: RIGHT , LEFT, UPPER AND LOWER BORDERS.

Helps in finding position and enlargement of heart as in-

4.  Dextrocardia.
 Pericardial effusion.
 Dilated cardiomyopathy.



PROCEDURE:

a) RIGHT BORDER:
First percuss for liver dullness →take 1 intercostal space above →from here go medially →presence
of dull note at right sternal border signifies right border of heart.

b) LEFT BORDER
Localise the apex beat →take 1 intercostal space above →from here go medially → presence of dull
note signifies left border of heart.


AUSCULTATION

AREAS OF AUSCULTATION:
A) MITRAL AREA: 5
th
left intercostal space in the midclavicular line.
B) TRICUSPID AREA: 4
th
left intercostal space just lateral to lower end of sternum.
C) 1
st
AORTIC AREA: 2
nd
right intercostal space, close to sternum.
2
nd
AORTIC AREA /ERB’S AREA:3
rd
left intercostal space, close to sternum.
D) PULMONARY AREA: 2
nd
left intercostal space, close to sternum.
E) GIBSON’S AREA: 2
nd
left intercostal area away from sternum.(PDA murmur is best heard here)
F) OTHER AREAS: carotid, supraclavicular, axillary areas.
Back- interscapular, infrascapular areas ( bruits in the back).

AUSCULTATE THE AREAS FOR FOLLOWING SOUNDS:
1) HEART SOUNDS-S1, S2, S3 ,S4.
 INTENSITY (soft/loud)
 SLPITTING OF SOUNDS.

a) S1- produced by closure of atrioventricular valves.(M1 + T1)
→ SOFT S1: mitral and tricuspid regurgitation, mitral and tricuspid stenosis.
→ LOUD S1: tricuspid stenosis , high output states.
→ SPLITTING S1: RBBB with pulmonary hypertension, ebsteins anomaly.
→ REVERSE SPLITTING: Right ventricular pacing, ectopic beats from RV.

b) S2-Produced by closure of aortic and pulmonary valves.(A2 + P2)

5. → SOFT S2: Aortic/pulmonary valve calcification.
→LOUD S2: Systemic and pulmonary hypertension.
→SPLIT S2: Atrial septal defect, pulmonary embolism , right ventricular
failure.
→REVERSE SPLITTING S2: LBBB, Aortic stenosis (severe).



c ) S3/PROTODIASTOLIC SOUND/VENTRICULAR GALLOP:
Auscultate with bell of stethoscope at apex.
→ PHYSIOLOGICAL: Children and athletes.
→ PATHOLOGICAL: High output states ,ASD, VASD, PDA, IHD.



d) S4/PRESYSTOLIC GALLOP/ATRIAL GALLOP:
→ Hypertrophic cardiomyopathy, systemic hypertension.



2) ADDED SOUNDS:
a) OPENING SNAP.
b) EJECTION CLICK.
c) GALLOP RHYTHM.
d) ATRIAL GALLOP.
e) VENTRICULAR GALLOP.




3) PERICARDIAL RUB:
→ Viral pericarditis, tuberculous pericarditis, acute rheumatic fever, SLE.



4) HEART MURMURS:

→ They are relatively prolonged series of auditory vibrations produced due to turbulence that arise
when blood velocity increase due to increased flow or due to flow through a constricted or irregular orifice.

Murmurs should be described in the following way:
 Area over precordium where murmur is heard.
 Whether murmur is systolic/diastolic.
 Timing and character of murmur(ESM,PSM,MDM,EDM)
 Intensity of murmur(grading).
 Pitch of murmur (low/high).
 Whether murmur is best heard with bell or diaphragm of stethoscope.
 Conduction of murmur.

6.  Variation with respiration( Lt sided murmurs best heard in expiration & vice versa).
 Posture in which murmur is best heard.






LEVINE AND FREEMAN’S GRADING OF MURMURS :


SYSTOLIC MURMUR

GRADE:
1.very soft.(heard in quiet room)
2.soft.
3.moderate.
4.loud with thrill.
5.very loud with thrill (heard with stethoscope).
6.very loud with thrill (even when stethoscope is slightly away from chest wall)



DIASTOLIC MURMURS.

GRADE:
1.very soft.
2.soft.
3.loud.
4.loud with thrill.