THE PEDIATRIC DIAGNOSTIC EXAMINATION - PART 4 doc

History 231 TABLE 9–1 History Checklist (Continued) Child •Birth weight and gestational history? Abn/nl ___ •Any cyanosis with crying? Y/n___ • Feeding and activity levels? Abn/nl ___ • Family history of heart problems? Y/n___ •Murmur? Y/n___ •Respiratory problems? Y/n___ •Genetics abnormal in family? Y/n__ •Diabetic history? Y/n___ • Frequent respiratory illness? Y/n___ • Activity level normal? Y/n__ •Growth parameters okay? Y/n___ •Spells or seizures? Y/n___ • Shortness of breath on ex ertion (SOBOE)? Y/n___ • Family history of sudden death under 50 years in close relative? Y/n__ • Other information from parent or family? Y/n___ Adolescent •Birth weight and gestational history? Abn/nl ___ •Any cya nosis with crying? Y/n___ • Feeding and activity levels? Abn/nl ___ • Family history of heart problems? Y/n___ •Murmur? Y/n___ •Respiratory problems? Y/n___ •Genetics abnormal in family? Y/n__ •Diabetic history? Y/n ___ • Frequent respiratory illness? Y/n___ • Activity level normal? Y/n__ •Growth parameters okay? Y/n___ •Spells or seizures? Y/n___ • SOBOE? Y/n___ • Family history of sudden death under 50 years in close relative? Y/n ___ •Severe chest pain? Y/n___ Describe what makes it better or worse?___ •Severe dizziness with exercise? Y/n___ •Syncope with or after exercise? Y/n___ • Palpitations? Y/n___ Heart racing? Y/n___ •Drug use or abuse ? Y/n___ •Migraine, gait unsteadiness, or seizure family history? Y/n___ •Arthritis, joint swelling, rash, and/or pain? Y/n___ •Chest or significant head trauma? Y/n__ •Diet history/sleep history/water intake/meal history? ab n/nl___ •Prior tests (ECG/chest x-ray/echo/others)?__________________ • Other questions or other symptoms? Y/n___ Abbreviations: Abn = abnormal; nl = normal; Y = Yes; n = no; SOBOE = shortness of breath on exertion. Physical Examination Inspection General inspection is critical to the examination in all age groups. Alertness of the infant, cry characteristics, skin color and turgor, finger clubbing, respiratory breathing patterns, and hydration all may relate to cardiovascular status. Capillary “flush” timing can be helpful for circulatory assessment. Cyanotic newborn infants are often a cardiac emergency when they present with central cyanosis, particularly if they have PDA-dependent le sions. Similarly, associated weak cry or lethargy may suggest significant heart disease. Central cyanosis should be assessed by an oxygen saturation monitor or arterial blood gas determination in both room air and an increased oxygen (preferably 100%, if possible) environment (hyperoxia test). Acrocyanosis (cyanosis of the extremities) is often present during the first few hours aft er birth and is assessed by the Apgar scoring system at 1- and 5-minute intervals and, if persistent, for longer intervals. It is usually due to autonomic instability and is rarely of cardiac significance. Localized peri pheral cyanosis owing to autonomic nervous system effects is termed the harlequin effect. It may be noted for several weeks after birth. These areas of color change corresponding to body segments are caused by infant posi- tio n change and resolve with maturation of the autonomic nervous system. Determine infant size as large, small, or appropriate for gestational age by standard growth charts (see Chapter 5). Pedal edema and abdom- inal ascites may reflect cardiac or noncardiac newborn abnormalities and also must be considered in cardiac evaluation. Dysmorphic infants or those who have a known syndrome should raise suspicion for frequently associated cardiac anomalies (TABLE 9–2). Height, weight changes, and sexual maturation are evident between the ages of 8 and 12 years. Growth is different between girls and boys, with female development and sexual maturation occurring 1 to 2 years earlier. Cardiac examination must consider these Tanner stages (1–5) of maturation or pubertal development when examining patients in this age range. 232 Chapter 9: The Cardiovascular System KEY FINDING TABLE 9–2 Cardiac Syndrome: Pediatric Cardiac Anomaly Correlates Down syndrome: A-V canal > VSD > tetralogy of Fallot > Eisenmenger syndrome Turner syndrome: C/A > AS > aortic dilatation Noonan syndrome: PS > pulmonary dysplasia > A-V canal, HCM Marfan syndrome: aortic dilatation > MVP > aortic aneurysm Ehl ers-Danlos syndrome: aortic dilatation, aneurysm LEOPARD syndrome: pulmonic stenosis, VSD Rubella syndrome: PDA, peripheral pulmonic stenosis DiGeorge syndrome: Tetralogy of Fallot > truncus arteriosus > aortic arch anomalies Abbreviations: A-V = atrioventricular; VSD = ventriculolseptal defect; PS = pulmonary stenosis; HCM = hypertrophic cardiomyopathy; MVP = mitral value prolapse; PDA = patent ductus arteriosus. Palpation Palpation of the precordium is useful to detect location and intensity of the heartbeat. If turbulence of flow is significant (murmur > 3/6, see “auscultation” section below) the examiner will feel a vi bration or “thrill” over that area. In addition, extracardiac palpation of the liver and extremities for swelling also identifies fluid accumulation in heart disease. Peripheral pulse palpation a nd upper and lower extremity blood pressure measurements are very important, especially during the first 24 to 48 hours after birth. Increased or diminished pulse amplitude and blood pressure measurements may suggest a cardiovascula r abnormality. Cardiac heart rate monitoring will show a wide range of normal newborn heart rates during the first 2 to 3 days after birth. Infant heart rates normally can increase to 200 beats/min during this ti me but also can decrease to 50 to 60 beats/min, especially with an increased vagal effect during the first 1 to 3 days following birth. See TABLE 9–3 for the normal ranges of heart rates in infants, children, and adolescents. Percussion Card iac percussion is important to delineate heart borders and size. Because of the differential density between heart tis- sue and lung, a dull sound will become more resonant as the border is crossed f rom heart to lung. In addition to cardiac percussion, percussion of both the lung and the liver is important to assess for dullness in the event of fluid accumulation. Auscultation General Considerations Cardiac murmurs are audible sounds in the range between 20 and 2000 Hz that are produced by the heart and blood vessels. Murmurs are by far the most common cause for cardiac consultation in the pediatric age group. Although the large majority of murmurs are innocent or functional, they still must be separated from those that are caused by cardiac anomalies (pathologic murmurs). About 50 percent of school-age children will have innocent murmurs sometime during childhood . Physical Examination 233 KEY FINDING KEY FINDING KEY FINDING TABLE 9–3 Normal Pulse Rates for Age Age Pulse Rate Infant 100–200 Toddler 90–150 Preschooler 80–140 School age 70–120 Adolescent 60–100 Source: APLS: Pediatric Emergency Medicine Course, ACEP/AAP, 3rd edition, 2004, Table 4-3, p. 43. Auscultation remains an important cardiac physical diagnostic skill for murmur identification. Unfortunately, these skills have eroded, are not taught as well, or have been ignored with increas ed reliance on newer cardiac imaging such echocardiography, computed tomography (CT) scan, and magnetic resonance imaging (MRI). This deterioration of clinical heart auscultation skills has occurred not only at the medical student level but also at the resident, fellow, and staff levels. It is important to perform the pediatric cardiac examination in a quiet area with auscultation of the heart sounds at each respective cardiac valve s ite (FIGURE 9–2). One should routinely examine patients with the stethoscope bell and diaphragm in both the supine and upright posi- tions in newborns, infants, and children. Examine preadolescents and adolescents in the standing a nd/or left lateral decubitus position to allow an optimal evaluation of the mitral valve. The bell will detect best low- frequency sounds, and the diaphragm will detect best the higher fre- quencies; medium-frequenc y sounds are heard equally well with both. The use of selected maneuvers such as position change, held expiration and inspiration, Valsalva maneuver, and exercise often can provide addi- tional findings to differen tiate between innocent and pathologic murmurs. Most expert examiners will use a pattern sequence that starts with the first and second heart sounds (S 1 and S 2 ) at each of the four valve sites. Document other heart sounds and the timing, location, quality, and pitch of a murmur. 234 Chapter 9: The Cardiovascular System Pulmonic area Nipple Bicuspid (mitral) area Aortic area Tricuspid area FIGURE 9–2 Cardiac Valve Areas for Precordial Auscultation. (From Van de Graaff KH: Human Anatomy. New York: McGraw-Hill, 2002, Fig. 16.13, p. 554.) Note changes in sounds and murmurs and splitting of a heart sound, particularly S 2 . The first heart sound results from the mitral valve–tricuspid valve closure that occurs early in ventricular contraction. This is best heardwith slower heart rates and at the respective mitral an d tricuspid valve sites. Mitral and tricuspid valve closure is usually a single S 1 in younger patients. Anything that delays rig ht tricuspid valve closure likely will cause an S 1 split. After the onset of ventricular contraction, the semilunar valves (aortic and pulmonic) open silently to allow ventricular ejection while the atrioventricular (A-V) valves remain closed (FIGUR E 9–3). After ventricular ejection, the semilunar valves close rapidly, producing the second heart sound (S 2 ). The second heart sound is heard best at the base at the aortic and pulmonic valve sites. Aortic valve closure occurs earlier, and its sound typically is louder than that of pulmonic valve closure. Physical Examination 235 FIGURE 9–3 The Cardiac Cycle. (After CJ Wiggers: Nelson Textbook of Pediatrics, 17th ed. 2004, Fig. 413–3, p. 1488.) The normal splitting of the second heart sound is largely influenced by the inspiratory filling effects on the right side of the heart. During expiration, both the aortic and pulmonic valve close nearly at the same time, resulting in a single or narrowly split S 2 . It is important to char- acterize S 2 accurately as to normal splitting and movement with respi- ration or if there is “fixed” splitting, which is due to persistently increased return to the right side of the heart during diastole. Other sounds, such as an S 3 sound, may be normal unless it is a continuous S 3 gallop in patients with heart failure. On rare occasions, an S 4 sound may be heard and is always abnormal. Properly obtained blood pressures and pulses in the upper and lower extremities are important, particularly in younger infants and children suspected of having hyperten sion. The blood pressure cuff should be appropriately sized for age and encircle at least two-thirds of the dis- tance between the elbow and the shoulder (FIGURE 9–4). Machine (Dinamap) pressures are 10 mm Hg higher in systole and 5 mm Hg high er in diastole than auscultation pressures. Palpation of the pulse amplitude in the radial and femoral pulse areas and determination of pulse delay or pulse differences between upper and lower extremities are i mportant to detect cardiac anomalies. Pathologic Heart Sounds Systolic murmurs are usually described as holosystolic, systolic ejection, early systolic, midsystolic, or late systolic (FIGURE 9–5). Holosystolic murmurs may result from A-V regurgitation but are more common with ventricu loseptal defects (VSDs) in pediatrics. Sy stolic ejection murmurs are crescendo-decrescendo (rising and falling) and occur more often from either ventricular outflow tract abnormalities or stenosis of semilunar valves . Diastolic murmurs are less common than systolic murmurs but, when present, are due to semilunar valve regurgitation, stenosis of an A-V valve, or a “functional” stenosis from increased flow across an A-V valve (FIGURE 9–6). 236 Chapter 9: The Cardiovascular System FIGURE 9–4 Sphygmomanometer Sizes: Large Adult, Adult, and Child Sizes on Left and Infant and Newborn Sizes on Right. Physical Examination 237 Holosystolic Ejection Early systolic Late systolic Systole S Q P R S1 S2 T FIGURE 9–5 Systolic Murmur Classification. FIGURE 9–6 Diastolic Murmur Classification. Early Mid- Late R P Q S T Diastole S1 S2 Diastolic murmurs are noted in early or protodiastole, middiastole, or late diastole (presystolic). Protodiastolic murmurs are usually from A-V valve insufficiency; middiastolic murmurs are flow-related or st enotic A-V valve s with a blowing ejection type of sound, and presystolic mur murs are caused by stenotic or A-V valve obstructions. Con- tinuous mur murs usually are extracardiac in locations distal to the se milunar valves; e xcept for venous hums, most continuous murmurs are pathologic. Systolic ejection clicks typically are associated with semilunar (aortic/ pulmonic) valve stenosis or vessels that are dilated distal to the valve. Midsystolic cli cks are associated with A-V (mitral or tricuspid) valve prolapse. Any murmur will need accurate description and documenta- tion regarding timing, grade, intensity, location, duration, pitch, and qualit y. It is important to locate a murmur in the cardiac cycle. This will be either in systole, diastole, or continuous with reference to the first and second heart sounds. Most examiners should use the Levine grad- ing scale for murmur intensity from grades 1 to 6 in systole and diastole; some will grade diastolic murmurs from 1 to 4 because grade 5/6 and 6/6 diastolic murmurs are very rare. Innocent Murmurs Innocent murmurs are usually systolic ejection, are vir tually never holosystolic, and usually change intensity with position. Such murmurs usually are grade 1/6 or 2/6 but rarely over grade 3/6; thus palpable thrills are virtually none xistent. After the newborn age, the vast majority of murmurs are innocent, the most common of which is the Still’s murmur, an early and midsystolic vibratory, buzzing, twanging-string, or a harmonic- musical murmur. It is heard b est with the stethoscope bell at the left lower upper sternal border and apex areas of the chest in the supine position. Its intensity changes with position, and it originates from left ventricle (LV) outflow or LV papillary muscle sites. The murmur is not holosystolic but occurs in early and midsystole and is usually of low intensity and does not transmit well or radiate to other parts of the precordium. Exercise, anxiety, ane mia, fever, and held expiration will increase the intensity. It can be heard in the newborn but more often occurs between 6 months and 8 years of age and less frequently in the adolescent. The pulmonary outflow s ystolic ejection murmur is the second most common innocent murmur, becoming increasingly prevalent in preadolescents and adolescents. It is heard best with the stethoscope diaphragm in both children and adolescents at the second and third left intercostal space in the supine position. An increase in right ventricular heart flow or turbulence usually causes the murmur. Exercise, anxiety, anemia, fever, and the maneuver of volun tarily held inspiration will increase the murmur’s intensity. In neonates and premature infants, the murmur of peripheral pulmonary stenosis is quite common but typically will resolve by 3 to 6 months of age. This is a low-intensity systolic ejection murmur over the chest, axilla, and back caused by relative hypoplasia and branching of the newborn pulmonary artery system. With pulmonary vascular system maturatio n and the resulting decrease in pulmonary resistance, physiologic pulmonary 238 Chapter 9: The Cardiovascular System vessel enlargement, and normalizing pulmonary artery pressures, most such murmurs will abate with time. Venous hums are common in infants and children. They are innocent murmurs that occur in early systole and early d iastole and sound like a “to-and-fro hum” continuously throughout the cardiac cycle. Such murmurs are best heard in the sitting position and on the right side either at the base or the third right interspace. Th is murmur is most com- monly noted in the 3- to 8-year age group. The murmur originates from the jugular venous and innominate–superior vena caval system. Most venous hums will either decrease or disappear when th e patient is placed in the supine position or if the neck is turned. An arterial bruit or murmur noted in the carotid vessels at or above the clavicle is the supraclavicular innocent murmur. It is not ed more often in adolescents and heard best in the sitting patient with the bell of the stethoscope on the right side, has low intensity, and is heard best in early systole. Origin of the murmur is from increased act ive blood flow in the brachiocephalic vessels. A complete and systematic cardiac and peripheral vascular system examination will help to differentiate innocent from abnormal or pathologic murmurs. Obviously, murmurs assoc iated with congestive heart failure, cyanosis, and dysrhythmias are not innocent. TABLE 9–4 summarizes key findings. Physical Examination 239 TABLE 9–4 Key Pediatric Cardiovascular Findings Cyanosis Tachypnea Tachycardia Murmur Pulse amplitude/delay abnormality Hepatomegaly Apnea Clubbing Bradycardia Irregular cardiac rhythm Edema/ascites/anasarca Fatigue on feeding Pallor Systolic ejection clicks Midsystolic clicks Opening snap Gallop (S 3 /S 4 ) Friction rub Rash Fever Chorea Abnormal heart sounds Abnormal heart sound location Arthritis Cardiac surgical incision [...]... 110 117 94 108 112 119 96 109 113 120 38 52 56 64 43 57 61 69 47 61 65 73 50 64 68 76 52 66 70 78 39 53 57 64 44 58 62 69 48 62 66 73 50 64 68 76 53 67 71 78 39 53 57 65 44 58 62 70 48 62 66 74 51 65 69 76 53 67 71 79 40 54 58 65 45 59 63 70 49 63 67 74 52 66 70 77 54 68 72 79 41 55 59 66 46 60 64 71 50 64 68 75 52 67 71 78 55 69 73 80 41 55 59 67 46 61 65 72 50 64 68 76 53 67 71 79 55 69 73 81 42 56... 106 120 1 24 131 109 123 127 1 34 112 125 129 136 1 14 128 132 139 116 130 1 34 141 108 122 126 133 111 125 128 136 113 127 131 138 116 130 1 34 141 118 132 136 143 110 1 24 128 135 113 126 130 138 115 129 133 140 118 131 135 143 120 1 34 138 145 111 125 129 136 1 14 128 132 139 117 130 1 34 142 119 133 137 144 121 135 139 146 112 126 130 137 115 128 132 140 117 131 135 142 120 1 34 137 145 122 136 140 147 60 75... 121 88 102 106 113 92 105 109 117 94 108 112 119 96 110 1 14 121 98 111 115 123 89 103 106 1 14 92 106 110 117 95 109 113 120 97 111 115 122 98 112 116 123 34 49 54 61 39 54 59 66 44 59 63 71 47 62 66 74 50 65 69 77 35 50 54 62 40 55 59 67 44 59 63 71 48 63 67 75 51 66 70 78 36 51 55 63 41 56 60 68 45 60 64 72 49 64 68 76 52 67 71 79 6 7 8 9 243 10 11 12 50th 90th 95th 99th 50th 90th 95th 99th 50th 90th... 90th 95th 5th 10th 25th 50th 75th 90th 95th 37 52 56 64 42 57 61 69 46 61 65 73 50 65 69 77 53 68 72 80 38 53 57 65 43 58 62 70 47 62 66 74 51 66 70 78 54 69 73 81 39 53 58 66 44 58 63 71 48 63 67 75 51 66 71 78 55 69 74 81 39 54 58 66 44 59 63 71 48 63 67 75 52 67 71 79 55 70 74 82 Blood Pressure Levels for Boys by Age and Height Percentile 1 242 2 3 4 5 50th 90th 95th 99th 50th 90th 95th 99th 50th 90th... 103 107 1 14 84 97 101 108 85 99 103 110 87 100 1 04 111 88 102 106 113 90 103 107 1 14 85 98 102 109 87 100 1 04 111 88 102 105 113 90 103 107 1 14 91 105 108 116 86 100 1 04 111 88 101 105 112 89 103 107 1 14 91 1 04 108 115 93 106 110 117 88 101 105 112 89 103 107 1 14 91 1 04 108 115 92 106 110 117 94 107 111 118 89 102 106 113 91 1 04 108 115 92 106 109 116 94 107 111 118 95 109 112 120 90 103 107 1 14 91 105... will vary depending on the age of the patient Avoid speaking too loudly to an infant or child Involve the parent in the examination, and get the parent’s historical input during the cardiovascular system examination Sitting down rather than towering over infants and children is helpful Often the infant or toddler will be more comfortable in the parent’s arms rather than on the examination table Newborn... 64 79 83 91 65 79 84 92 66 80 85 93 67 82 86 94 69 84 88 96 95th Blood Pressure Levels for Boys by Age and Height Percentile 13 14 244 15 16 17 50th 90th 95th 99th 50th 90th 95th 99th 50th 90th 95th 99th 50th 90th 95th 99th 50th 90th 95th 99th 1 04 117 121 128 106 120 1 24 131 109 122 126 1 34 111 125 129 136 1 14 127 131 139 105 118 122 130 107 121 125 132 110 1 24 127 135 112 126 130 137 115 128 132 140 ... the newborn and during the first year of life Although they run higher than the standard cuff, they can be useful for trending purposes Abnormalities of blood pressure will need renal, cardiac, and endocrine evaluation in any age group In addition to a full cardiac evaluation, the lung examination by percussion, palpation, and auscultation is also part of the cardiovascular examination because of the. .. 92 106 110 117 94 107 111 119 95 109 113 120 97 111 115 122 99 113 117 1 24 101 115 119 126 92 106 110 117 94 107 111 118 95 109 112 120 96 110 1 14 121 98 112 116 123 100 1 14 118 125 102 116 120 127 94 108 112 119 95 109 113 120 97 110 1 14 122 98 112 116 123 100 1 14 117 125 102 115 119 127 1 04 118 122 129 96 110 1 14 121 97 111 115 122 99 112 116 123 100 1 14 118 125 102 115 119 127 1 04 117 121 129 106... 81 57 71 75 82 58 72 76 83 59 73 77 84 54 68 72 80 56 70 74 81 57 71 75 82 58 72 76 83 59 73 77 84 58 72 76 83 59 73 77 84 60 74 78 86 61 75 79 87 62 76 80 88 11 12 13 247 14 15 50th 90th 95th 99th 50th 90th 95th 99th 50th 90th 95th 99th 50th 90th 95th 99th 50th 90th 95th 99th 100 1 14 118 125 102 116 119 127 1 04 117 121 128 106 119 123 130 107 120 1 24 131 101 1 14 118 125 103 116 120 127 105 118 122 . 94 95 44 44 45 46 47 48 48 90th 100 101 103 105 107 108 109 59 59 60 61 62 63 63 95th 1 04 105 107 109 110 112 113 63 63 64 65 66 67 67 99th 111 112 1 14 116 118 119 120 71 71 72 73 74 75 75 4. 85 85 87 88 89 91 91 43 44 44 45 46 46 47 90th 98 99 100 101 103 1 04 105 57 58 58 59 60 61 61 95th 102 103 1 04 105 107 108 109 61 62 62 63 64 65 65 99th 109 110 111 112 1 14 115 116 69 69 70 70. 92 93 47 48 48 49 50 50 51 90th 100 100 102 103 1 04 106 106 61 62 62 63 64 64 65 95th 1 04 1 04 105 107 108 109 110 65 66 66 67 68 68 69 99th 111 111 113 1 14 115 116 117 73 73 74 74 75 76 76 4 50th