Examination of the Cardiovascular System

Examination of the Cardiovascular SystemThe barbarian should be undressed befittingly to the waist. In the older boor, the examination easily performed with the patient academic term over the edge of the backside or even on a chair. Preferably, examine the younger child on the p arnts lap. Removing a toddler from his p arents is less promising to yield good clinical signs and more similarly to yield a screaming child. For examination of femoral metres, the child should be in the supine position. prompt your devotes by expungebing them against each other.STEPS OF THE delegateYou should use the middle three feels of your dominant overturn to experience the momentums against the underlying bone. The finger tips are used for palpation as they have maximum sensitivity. plot of ground palpating, the artery is stabilized by the proximal and distal fingers and the thrust of the twinkling is felt by the middle finger. Partial occlusion of the artery by the distal finger improv es the thrust of the pulse draw in on the middle finger.Palpate all the pulses listed on a small-scaleer floor first on the violentress and then on the go forth over(p) side. Always compare the respective pulses on both sides except the carotids. In case of carotids, palpitate both sides faecal matter induce cerebral ischemia and tin can cause the patient to faint.Carotid (dont palpate both sides simultaneously) Palpated at the level of thyroid gristle on the median border of the sternomastoid muscle either with finger tips or thumb ( leftfield thumb for the undecomposed side and vice versa)Brachial Palpated with the elbow flexed along the medial aspect of the lower end of the armRadial felt at the lower end of the radius on the anterior aspect of the wrist, medial to the styloid process with the patients forearm slightly pronated and wrist semiflexedFemoral (DO NOT FORGET FEMORALS) felt in the middle of the groin with the wooden leg slightly flexed and abducted a nd foot outwardly rotated.Dorsalis pedis can be felt on the dorsum of the foot craveance to the extensor hallucis tendon in the middle third of the footPosterior tibial felt posterior to the medial malleolus and anterior to the Achilles tendon.For assessing the pulse rate, use brachial pulse in an infant or toddler and radial pulse in older childrenWhile counting the pulse rate, count for 15 seconds and multiply by 4. But tell the examiner that ideally, you would like to count for one minute. However, if the pulse is irregular, then count for one adept minute and also count the heart rate by auscultation.Rhythm while looking for the rhythm, one looks for the perturbation between the pulse waves and comment on their regularity.VolumeThis is a highly subjective sign. It desc roastes the thrust (expansion) of the pulse wave and reflects the pulse storm.If high volume, always break-dance for collapsing nature. (Hold the right forearm of the patient by your fall in such a way a s the radial artery is under the head of the metacarpals of our go across. glom the patients entire velocity limb vertically by 90and feel for the sudden and exaggerated rise and fall of the pulsations of radial artery.)Character This describes the form of the wave and various types are decided by the rise, peak and waning of the wave. It is best appreciated in carotids.Radio femoral learn (femoral pulse appears next a time go over after radial suggests coarctation of aorta)POST- trade union movementMake sure you dont leave the child undecided.Thank the child/ parent for co act if no further examination is plannedVIGNETTECharacteristics of pulse should be described as followsRateRhythmVolumeCharacterSymme moveRadio-femoral delayRateComment on rate as normal, tachycardia or bradycardia based on term specialised heart. In general, for children over 3 years of while pulse rate 100 beats per minute is tachycardia and pulse rate Tachycardia has poor specificity and always m ake sure child is not anxious/ febrile before attributing significanceBradycardia in a child is usually point to underlying pathology once exercise (athletes), drug intake (Digoxin, beta blockers) is ruled out.Rhythm describe as regular, Regularly irregular and Irregularly irregularRegular there is a normal variation of heart rate on breathing fistula arrhythmia. It is present in most children.Regularly Irregular abnormal beats occur at regular intervals pulsus bigeminus, coupled extrasystoles (digoxin toxicity), Wenckebach PhenomenonIrregularly Irregular no specific gaps between the waves Extrasystoles are common in normal children and disappear with exercise. Atrial fibrillation is another common condition which causes an irregularly irregular pulse. Comment on the pulse deficit i.e. the difference between heart rate and pulse rateVolumeHigh volume anemia, carbon dioxide retention or thyrotoxicosis woeful volume pulse is seen in low cardiac output states.CharacterSlow risi ng and plateau (pulsus parvus et tardus) dreaded aortic stenosisCollapsing pulse e.g. aortic incompetencePulsus Paradoxus- pulse is weaker or disappears on inspiration e.g. Constrictive pericarditis, tamponade, status asthmaticusJerky pulse normal volume, rapidly rising and ill sustained.-suggestive of hypertrophic obstructive myocardiopathyPulsus bisferiens deuce peaks felt during systole, seen in the presence of moderate artic stenosis and severe aortic regurgitationPulsus alternans sp illumine second wave with alternate depleted and large waves seen in severe left ventricular failure and arrhythmiasSymmetryUnequal or absent pulses may be suggestive of previous surgery e.g. Blalock-Taussig shunt, repaired coarctation, cervical rib or absent radial pulseOSCE CHECKLISTPRIOR TO THE taxHand washing or using alcohol rubAsks the name and age of the child, if already not told by the examinerExplains the purpose of his/ her visit and what he/ she is going to do personates the pat ient appropriatelyTASKUses the middle three fingers of the dominant hand to palpate the pulsesPalpates all the pulses first on one side and then on the other sideCompares pulses bilaterallyDoes not palpate the carotids simultaneouslyCounts the pulse rate at least for 15 secondsIf pulse is irregular, then counts for one full minute and also counts heart rate lookings for Radio femoral delayWhile describing the pulse, comments on rate, rhythm, character, volume, symmetry and radio-femoral delayPOST- TASKMakes sure that the child is not left exposed give thanks the child / parent for co procedureTask MANUAL Measurement of occupation contractPRIOR TO THE TASKMercury sphygmomanometer should be used as aneroid sphygmomanometer loses accuracy on tell usage.Choose the appropriate size cuff the cuff bladder should cover at least 2/3 of the length of the arm and 3/4 of the circumference . Cuff size should always be documented.Make sure that the child is calm and not crying or agitatedCh ild can be either seated or in the supine positionAny clothing over the arm should be removedTHE TASKThe conclave is to measure BP in the right arm in a calm but awake subject. If conditions differ from this they should be documented with the reading.The elbow should be support and flexed and should be at the level of the heart.The cuff is wrapped around the upper arm with the bladder centered over the middle of the arm.Approximate estimation of the systolic blood pressure is done initially by inflating the cuff fully and then deflating slowly and smoothly while palpating the radial pulse. Systolic blood pressure is noted at the point when the radial pulse returns.Following this, the blood pressure is recorded by auscultatory method which is the more accurate measure. The s top offpage of the stethoscope is placed over the brachial artery along the medial aspect of the lower end of the arm below the edge of the cuff. The cuff should be lofty to 30 mm above the palpatory systolic blood pressure and then deflated slowly and smoothly at the rate of 2-3 mmHg per second. Systolic blood pressure is recorded at the point when clear, repetitive tapping heavys are just heard. Diastolic blood pressure is recorded when the rights disappear.In some children, instead of disappearing, the sounds put out first before disappearing. In this case, the value at which the sounds muffle should be recorded as the diastolic pressure if the difference between the point of muffling and fade of the sounds is greater than 10 mmHg.POST- TASKMake sure you do not leave the child exposed.Thank the child/ parent for co operation if no further examination is plannedWhile interpreting the readings, the state of the child should be taken into account. Values should be compared to normal values with reference to the age/height and sex of child.VIGNETTEIn infants, instead of radial, brachial pulse should be palpated. Sometimes, auscultation can be difficult in infants in which case systoli c pressure by palpation should be documented.If measuring a lower limb pressure, the same cuff can be app double-dealingd to the lower leg and a foot pulse palpated.It is advisable to measure the blood pressure in both upper and lower limbs. When coarctation is suspected, it is imperative that blood pressure is recorded in both arms and one leg. The same should be done is cases of hypertension and in those who have had shunt surgeries as in Blalock Shunt.While enter blood pressure in the lower limb, a larger appropriate size cuff should be used and auscultation is done over the popliteal artery.The sounds which are heard while auscultating are called as Korotkoffs sounds and has five phases. Phase 1 is the first heard clear, tapping sound, phase 2 is intermittent murmur like sound, phase 3 is the loud tapping sound, phase 4 is the muffling of sounds and phase 5 is disappearance of the sounds.Occasionally, the sound might disappear after the Korotkoff sound phase 1 before reappearin g later. This auscultatory gap can lead to either underestimation of the systolic blood pressure (if prior estimation of blood pressure by palpation is not done) or overestimation of diastolic blood pressure is the auscultation is not continued till the end.In atrial fibrillation, phase 4 of Korotkoff sound should be used for recoding diastolic blood pressure.Pulsus paradoxus is best appreciated while recording blood pressure by auscultation and is identified by recording the value at which the tapping sounds are heard only during expiration and the value at which the sounds are heard both during inspiration and expiration. When the difference between the two values is greater than 10 mmHg, pulsus paradoxus is said to be present.Pulse pressure is the difference between systolic blood pressure and diastolic blood pressure. A weak pulse is associated with narrow pulse pressure and is seen in cardiac failure, shock, aortic stenosis and constrictive pericarditis. Pulse pressure is wide in aortic regurgitation, hyperthyroidism, anemia and febrile states.OSCE CHECKLISTPRIOR TO THE TASKWashes pass on or uses alcohol rubExplains the purpose of his/ her visit and what he/ she is going to doPositions the patient appropriatelyChooses mercury sphygmomanometerChooses the appropriate size cuffRemoves any clothing over the armTASKSupports the elbow and keeps it at the level of the heart.Wraps the cuff around upper arm with the bladder centered over the middle of armEstimates systolic blood pressure by palpatory methodUses brachial pulse in infants for palpatory methodEstimates systolic blood pressure by auscultatory methodUses diaphragm of the stethoscope for auscultationPOST- TASKMakes sure that the child is not left exposedThanks the child / parent for co operationRecords blood pressure as estimated by palpatory and auscultatory method including the site and the position of the childInterprets the blood pressureTask Evaluation of jugular vein venous pulsePRIOR TO THE TAS KThe room should be adequately lit for the assessment of jugular venous pulseThe patient should be in semi-reclining position with the trunk at 45 to the bed.The head and the back should be soundly supported with a pillow under the head.The head should be positioned in the midlineTHE TASKStand on the right side of the patient and assess the jugular venous pulse.The torch should be shined from the left in an oblique direction and the jugular pulsation is observedJugular venous pulse is located just lateral to the clavicular head of the sternomastoid muscle.Pulsations of the jugular veins should be differentiated from the carotid pulsations as discussed below.The jugular venous pressure is assessed by measuring the vertical distance between the top of the jugular venous pulsations and the sternal angle (angle of Louis). In cases where the top of the jugular pulsations is not visible at 45, increasing the reclining angle up to 90 can make the top of the pulsations obvious. The assessm ent is done when the child is breathing quietlyLook for hepato-jugular reflex. This performed by exerting firm and sustained pressure on the right upper quadrant of the abdomen and looking for an elevation in the jugular venous pressure by 2-3 cm.POST- TASKMake sure you do not leave the child exposed.Thank the child/ parent for co operation if no further examination is plannedVIGNETTEAssessment of jugular venous pressure is rarely important in the younger child. It is also difficult to obtain an accurate reading because of the short neck in childrenIt can be generally measured easily if the child is greater than 10 yearsJugular Venous PulsationCarotid PulsationPulse lateral to sternomastoidPulse medial to sternomastoidBetter seenBetter feltMultiple waves seenSingle waveAbdominal pressure makes the pulsations prominentAbdominal pressure has no effectValsalva caper makes the pulsations prominentValsalva maneuver has no effectCan be obliterated with pressureCannot be obliterated with pressureThe right jugular vein is in a straight line with the right atrium and is more likely to show the pressure effects than the left jugular vein which has more tortuous pass over and is more likely to kinked. This can lead to false elevation of the jugular pressure.In patients with highly elevated JVP, the pulsation may be seen only below the angle of jaw. In such cases, increasing the reclining angle to 60 or more makes the pulsations more obvious.Turning the head slightly towards the contralateral side can make the pulsations prominent, if the pulsations are not obvious.JVP consists of a, c and v waves and x and y descent. a wave is due to right atrial contraction, c wave is due to bulging of the tricuspid valve and v wave is due to atrial filing. x descent is due to atrial relaxation and y descent results from ventricular alter and tricuspid valve opening.The sternal angle (angle of Louis) is taken as the reference point as it roughly corresponds to the middle of the righ t atrium.JVP is elevated in congestive cardiac failure, fluid overload, constrictive pericarditis, pericardial tamponade, tricuspid stenosis and tricuspid regurgitation.Non-pulsatile elevation of JVP is seen in superior vena cava obstruction.a wave are absent in atrial fibrillation.Large a waves are caused either by hypertrophied right atrium in response to decreased right ventricular compliance as in pulmonary hypertension and pulmonary stenosis or contraction of atrium against resistance as in tricuspid stenosis.Cannon a waves are ogre a waves seen in early systole and is caused by contraction of the atrium against a closed tricuspid valve. It is usually seen in complete heart block and ectopics.Large v waves are seen in tricuspid insufficiency.Sharp x and Sharp y descents are seen in constrictive pericarditis and restrictive cardiomyopathy.OSCE CHECKLISTPRIOR TO THE TASKWashes hands or uses alcohol rubExplains what he/ she is going to doMakes sure that the room is adequately lit Positions the patient in semi-reclining position with the trunk at 45 to the bedSupports the head with pillow to ensure relaxation of the neckPositions the head in midlineTASKStands on the right side of the patient and assesses the right jugular venous pulse.Locates the jugular pulse correctlyIf the jugular pulse is not obvious, then makes it obvious by turning the head slightly to the left and shines the torch from left obliquely if necessaryMeasures the jugular venous pressure correctlyLooks for hepato-jugular reflex.POST- TASKMakes sure that the child is not left exposedThanks the child / parent for co operationLists the differences between carotid pulse and jugular pulseTask general inspection of the body with reference to cardiovascular systemPRIOR TO THE TASKIntroduce yourself to the child and carer and ask for permission to examineFor inspection, the room should be well lit. Ensure that the lights are turned on and the windows are openThe child should be undressed appropriate ly to the waist.In older child, the examination is easiest to perform while they sit over the edge of the bed or even on a chair witness the younger child on the parents lap.STEPS OF THE TASKLOOK GENERALGeneral well being Well/ Ill looking childInterest in the surroundings Sick child will not be interested size of it of the child thin small, thin tall, well nourished and tall, well nourished and short.Degree of breathlessness classify as none, mild or severe environs (Equipment) oxygen mask, nasal cannula, intravenous catheter, pulse oximetry, feeding tube/ gastrostomy,LOOK SPECIFICHead look at the size (microcephaly or macrocephaly) and shape (dolichocephaly) lawsuit Normal or dysmorphic features, malar flushConjunctiva pallor, jaundice (refer chapter on general examination)Mouth Using the pen torch, take a quick look in the oral fissure and look for the presence of age appropriate teeth, abnormal teeth and caries. Ask the child to stick their vernacular outwards and upwards towards the nose and examine the tongue for central cyanosis.Hands and fingers pallor clubbing polydactyly and syndactyly Oslers nodes Janeway lesions splinter haemorrhages. Examine both the hands quickly.Difference in colour between limbsPOST- TASKMake sure that the child is not left exposedThank the child / parent for cooperationVIGNETTEAlways think whether the findings combine to form a recognizable clinical syndrome.It is preferable to inspect the child in sunlight than in artificial light.Children with chronic cardiac conditions are usually thin and small for age.Breathlessness is classified as mild when the child has only tit recession, and there is no contraction of sternocleidomastoid or nasal flaring and severe when all three are presentMicrocephaly can be associated with some of the intrauterine infections and genetic disorders like congenital rubella syndrome and Edwards syndromeDolichocephaly (increased antero-posterior diameter) is seen in ex-pretermsSyndrom es with dysmorphic facial nerve featuresDowns syndrome almond shaped eyes (due to epicanthal folds) Brushfield spots (light colored spots in the iris) small, flat nose small mouth with a protruding tongue small, low set ears round faces flat occiputTurners syndrome prominent, posteriorly rotated auricles with looped helices and attenuated tragus infraorbital skin creases mildly foreshortened mandibleWilliams syndrome broad forehead short nose with broad tip full cheeks wide mouth with full lipsNoonans syndrome downwards slanting eyes with arched eyebrows epicanthal folds broad forehead nose with wide base and bulbous tip pointed mentumMarfans syndrome long, thin face deep-set eyes down-slanting palpebral fissures receding chin dolichocephaly malar hypoplasia enophthalmosDiGeorge syndrome small ears asymmetric facies small mouth and chinMalar flush plum coloured malar eminencesHutchinson (conical) incisor is seen in congenital syphilis (patent ductus arteriosus) and enamel hy poplasia in Ellis-van Creveld Syndrome (atrioventricular canal, ventricular septal defect, atrial septal defect, and patent ductus arteriosus).Caries tooth may be a cause of infective endocarditis in congenital heart disease.In preaxial polydactyly, the extra digit is on the radial (thumb) side while in postaxial polydactyly, it is on the ulnar (little finger) side of the hand.Oslers nodes are painful, red, raised lesions found on the hands and feet and is seen in infective endocarditisJaneway lesions are nontender, macular lesions, most commonly involving the medallions and soles and seen in infective endocarditis.Splinter hemorrhages appear as narrow, red to reddish-brown lines of blood that run vertically under nails. Splinter hemorrhage can be associated with infectious endocarditis, systemic lupus erythematosus, and traumaOSCE CHECKLISTPRIOR TO THE TASKWashes hands or uses alcohol rubExplains what he/ she is going to do and ask for permission to examinePositions and exposes th e child appropriatelyMakes sure that the room is adequately litTASKLooks for the following general pointsGeneral well beingInterest in the surroundingsSize of the childDegree of breathlessnessEnvironment (Equipment)Looks for the following specific pointsHead size and shapeFaceConjunctivaMouthHands and fingersDifference in colour between limbsPOST- TASKMakes sure that the child is not left exposedThanks the child / parent for co operationTask INSPECTION OF THE CHESTPRIOR TO THE TASKIntroduce yourself to the child and carer and ask for permission to examineFor inspection, the room should be well lit. Ensure that the lights are turned on and the windows are openThe child should be undressed appropriately to the waist.In older child, the examination is easiest to perform while they sit over the edge of the bed or even on a chairExamine the younger child on the parents lap.STEPS OF THE TASKLook tangentially from foot end of the bed in supine patients and from the sides in sitting patien ts.Look for the following and commentShape of the Chest symmetrical or asymmetricalSymmetry of pectus expansionScarsPulsations Observe for apical impulse, parasternal, suprasternal, epigastric pulsations.Spine for scoliosisPOST- TASKMake sure that the child is not left exposedThank the child / parent for cooperationVIGNETTECommon asymmetrical chestsPectus carinatum also called pigeon chest, blot of the chest characterized by protrusion of the sternum and ribs. It may occur as congenital abnormality or in association with genetic disorders such as Marfans syndrome, Morquio syndrome, Noonan syndrome, Trisomy 18, Trisomy 21, homocystinuria, and osteogenesis imperfecta.Pectus Excavatum also called funnel chest, deformity of the anterior circumvent of the chest producing sunken appearance of the chest. It may occur in rickets, Marfans syndrome and spinomuscular atrophy.Harrisons sulcus horizontal indentation of the chest wall at the lower margin of the thorax where the diaphragm att aches to the ribs. It may occur in conditions with increased pulmonary blood flow or chronic asthma.Scars lateral thoracotomy scar results from closure of patent ductus arteriosus, tracheoesophageal fistula repair and Blalock Taussig shunt. Central sternotomy scar is seen after open heart surgery and lobectomy. Children can have waste pipe scars in epigastrium, subclavian/axillary scars from pacemakers and scars following cardiac catheterization in the groin and neck.Pulsationsapical impulse will be shifted peripherally due to cardiomegaly, collapse of left lung or fluid in the right pleural cavityParasternal pulsations can occur due to right ventricular enlargement or enlarged left atrium pushing the right ventricle.The most common cause of suprasternal pulsations is dilated aorta due to aneurysm or markedly increased blood flow.Epigastric pulsation may be seen in thin children, right ventricular hypertrophy and abdominal aneurysm.Scoliosis should be looked for in the standing and not in sitting positionOSCE CHECKLISTPRIOR TO THE TASKWashes hands or uses alcohol rubExplains what he/ she is going to do and ask for permission to examinePositions and exposes the child appropriatelyMakes sure that the room is adequately litTASKLooks tangentially from foot end of the bed in supine patients and from the sides in sitting patientsLooks for the following points and commentsShape of the ChestSymmetry of chest expansionScarsApical impulse, parasternal, suprasternal, epigastric pulsationsSpine for scoliosisPOST- TASKMakes sure that the child is not left exposedThanks the child / parent for co operationTask PALPATION OF THE CHESTPRIOR TO THE TASKIntroduce yourself to the child and carer and ask for permission to examineThe child should be undressed appropriately to the waist.Position the older child so that they sit over the edge of the bed or lie down on the couchExamine the younger child on the parents lap.Warm your hands for palpationSTEPS OF THE TASKBe gentle with pa lpationApical ImpulsePlace the palm of the whole hand flat over left chest wall to get a general impression of the point of maximal impulse.Next, lay the ulnar border of the hand on the chest parallel to rib home where the impulse was felt and try to locate the bloom.Finally palpate with the fingertip of the index or middle finger to localize the apical impulse and define its character.Use the left hand to palpate the carotid artery to time the apical impulse.With the finger of the right hand still in place over the apex beat, palpate the manubriosternal joint (angle of Louis) which is present just below the suprasternal notch and is felt as a intumescency with the left hand. It corresponds to the second intercostal space. Slide the index finger and count down the next few intercostal spaces until you locate the intercostals space that is level with the apex beat. Look at the position of the apex with reference to the midclavicular line.If the apical impulse is not readily palpab le in the supine position, ask the child to lie on their left side.If the apex beat is not still palpable, try on the right side in case of dextrocardia.Parasternal pulsation and heaveWith the fingertips, palpate over the left sternal edge to find the parasternal pulsations.With the child lying in supine position, place a pencil lateral to the left sternal edge and look tangentially for lifting of the pencil.Next, place the base of your hand just lateral to the left sternal edge and palpate for a parasternal heave.If parasternal heave is present, try suppress it by exerting pressure with base of the hand.Thrills are best felt with fingertips. Time the belt with carotid or brachial pulse. Palpate the following expanses. point of the heart3rd to 5th intercostal space along the left sternal borderPulmonary area (left second intercostal space)Aortic area (right second intercostal space)Suprasternal areaCarotidsPOST- TASKMake sure that the child is not left exposedThank the child / par ent for cooperationVIGNETTEApical impulse is the farthest inferior and lateral maximal cardiac impulse on the chest wall. It results from the heart rotating, moving forwards and striking against the chest wall during systole. Apical impulse is normally felt in the 4th left intercostal space on the midclavicular line. It may be difficult to palpate in obese children and in pericardial effusion.Displaced apexTension pneumothorax and pleural effusion (push apex away from the lesion)Pulmonary fibrosis and collapse (pull towards the side of the lesion)Left ventricular hypertrophy apex is displaced down and outRight ventricular hypertrophy apex is displaced outwardsSkeletal abnormalitiesQuality of apical impulse (normal apex lifts the palpating fingers briefly)Sustained (increased bounteousness and duration) pressure overload (aortic stenosis)Hyperdynamic or forceful (increased amplitude but not duration) volume overload (mitral incompetence and aortic incompetence)Tapping palpable first heart sound of mitral stenosisParasternal pulsationsPalpable 2nd heart sound reflects pulmonary hypertension.Parasternal heave is present in right ventricular hypertrophy or left atrial enlargement pushing the right ventricle.There are three grades of parasternal heaveGrade I heave identified by lifting of the pencil entirely and not the heel of the handGrade II easily identified, can be suppressed with pressureGrade III lifts the heel of the hand and cannot be suppressed with pressureThrill is a palpable murmur that felt like a purring cat. While describing the thrill, describe the site and phase of cardiac cycle. When thrill is present, the accompanying murmur is by definition at least 4/6 in intensity.OSCE CHECKLISTPRIOR TO THE TASKWashes hands or uses alcohol rubExplains what he/ she is going to do and ask for permission to examinePositions and exposes the child appropriatelyWarms hands beforeTASKPalpates gentlyApical ImpulsePlaces the palm flat over left chest wall to get a general impressionKeeps the ulnar border of the hand parallel to rib spacePalpates with the fingertip to locate the apical impulsePalpates the carotid artery