Respiratory effort: Tachypnea, grunting, subcostal retractions, tracheal tug, and orthopnea Listen for crackles and wheezing which are usually symmetric Organ enlargement: Palpate for a soft, engorged liver and check for splenomegaly Remaining Examination Joints: Check for tenderness, redness, warmth, and swelling (see Chapter 60 Pain: Joints ) Neurologic: Check cranial nerve function Nutritional evaluation: Are the child’s height and weight reasonable compared with the parents’? Is the weight percentile significantly different than that for height? Ancillary Diagnostic Aids Chest radiographs (CXRs), electrocardiograms, and cardiac ultrasounds are not indicated in the evaluation of a murmur in asymptomatic patients, as they may be misleading and rarely add any useful information Therefore, they should be ordered selectively in patients who are symptomatic or in patients in whom the clinical assessment did not suggest an innocent murmur Electrocardiography (EKG or ECG) A 12-lead electrocardiogram, using ageand size-appropriate electrodes, should be readily available for screening and evaluation purposes The emergency provider should be able to assess significant rhythm disturbances, ischemic changes, and gross hypertrophy understanding that normal EKG parameters vary with the age group of the child (see Chapter 86 Cardiac Emergencies ) Chest Radiograph (CXR) Films should be taken in both posteroanterior (PA) and lateral views The physician should look for gross cardiac enlargement in the PA view, which may be determined in older children by a transverse diameter greater than 50% of the width of the thoracic cage In infants, the diameter normally may be considerably wider than that ratio Thymic shadows, scoliosis, rib abnormalities, and less-than-full inspiration may be confounding factors The lung fields should be evaluated for infiltrates and for increased or diminished pulmonary vascular flow Rib notching may be present secondary to longstanding coarctation of the aorta Familiarity with specific CXR patterns associated with CHD may be helpful Echocardiography Echocardiography is recommended for symptomatic patients with clinical evidence of heart failure or disease and asymptomatic patients with presumed pathologic murmurs and/or abnormal CXR or EKG findings The echocardiogram allows definitive diagnosis for many congenital cardiac lesions, determination of the severity of cardiac failure, differentiation of myocarditis from pericardial effusion, evaluation of intrathoracic pressure phenomena (tamponade, effusion, tumors), and discovery of malpositioned coronary arteries or coronary dilation, as in Kawasaki disease Pediatric echocardiograms require special expertise to perform and interpret and usually should be obtained in conjunction with pediatric cardiology consultation Limited Bedside Cardiac Ultrasound Limited bedside cardiac ultrasound performed by skilled pediatric emergency physicians can provide quick and useful information about cardiac function and the presence of a pericardial effusion Increasingly, it is being used in pediatric EDs to evaluate ill-appearing patients with suspected cardiac disease or hemodynamic instability Blood Studies Screening tests should be obtained based on what is found on the history and physical examination Studies that might be of value under specific circumstances include a complete blood cell count with differential, erythrocyte sedimentation rate and/or C-reactive protein, arterial blood gas measurements, cooximetry, blood culture, antistreptolysin titer, sickle cell screening, troponin, brain natriuretic peptide (BNP), and antinuclear antibody EVALUATION AND DECISION Neonates and infants (defined as