General Observations
Clinical Approach:
- Smile - enter the room with a warm smile with proper body language.
- Examiner -
- Greet the examiner and tell him that you have already washed your hands outside.
- Pay utmost attention to examiners opening statement - confirm name/age/sex of the child.
- Now turns toward the child and the caregiver.
- Greet the child and the caregiver.
- Introduce to them with a smile. Make a repo with them.
- Ask permission from the caregiver to examine the child and explain to the child that what you are going to do. Do not take permission from the child.
- Expose the child from nipples to the knees. However, keep the underwear on.
- Maintain the child's dignity especially of adolescent girls. Please do not remove the bra. Ask about scars, rather than looking for it. “Can you show me please?”
- We can use a bedsheet/towel/blanket.
- The child should be as flat on the bed as possible.
General observation :
- Observe from the end of the bed: Look at the surroundings and things connected with the patients,. find any clue - line, oxygen, any device attached, iv access.
- Is the child comfortable or in pain?
- Child look well or unwell -- --Well or unwell (conscious, toxic, pain, …)-- child looks unwell/comfortable lying on the bed
- Note the child's nutritional status - thin/well nourished/obese/short/tall --(--looks well-nourished and ‘I would like to plot his height and weight on a growth chart’ appropriate for age and sex
- Colour- cyanosis/pallor--Count the RR “10Sec.X 6”, recession-- not in obvious respiratory distress
- See the unusual facial features -head size -- --top 3 syndromes: Down’s, Williams, Digeorge
Other possible syndromes related to CVS: Turner’s, Noonan’s
-- has no dysmorphic features
GENERAL EXAMINATION:
Normally I examine the child at 45°. But if the child is restless, a baby etc, it is
acceptable to examine as the parent’s lap
“The child is lively, I am going to examine the child on the lap”
Try and talk to the child as much as you can. We are looking at the rapport.
Hand
· Clubbing (Test if in doubt) Examine the clubbing if present (angel, curvature, fluctuation & degree).
· Pallor (Compare pt.’s hand with yours)
· Perfusion (Capillary refill)
· Pulse (rate, character, volume and equal on both sides
Radial and brachial
count over 6 sec X10
Radio-radial delay
Radio-femoral delay
lift the arm up to detect hyperdynamic pulsation (e.g. aortic incompetence)
Feel both radial pulses and femoral pulses: absent femoral pulses, with normal or increased
brachial pulses, suggest coarctation (brachiofemoral delay is found only in adults with coarctation.)
Note: if cannot feel pulses – say ‘pulses are difficult to feel’ Femoral“leave to the end) - “I am going to feel the pulse in the groin here” – Make an attempt in a gentle way and if the child resists, leave it.
Other- Janeway lesion, Osler nodes, Tuberous and tendon xanthomas of familial hypercholesterolemia
Bony abnormalities: Absent Radii (VACTERYL Syndrome), Absent Thumb (Holt-Oram Syndrome)
BP at the end
(there is no clubbing. capillary refill time is less than 2 seconds. pulse is .. bpm regular normovolumic. there is no radioradial or radiofemoral delay.)
Head
Eyes: Sclera – Jaundice ( Congestive cardiac failure à Hepatic congestion)
Conjunctive – Pallor (Anaemia)
Face: Mitral flush / malar flush Polycythaemia (Cyanotic heart disease à Increased haematocrit)
Tongue: Central cyanosis ( Right to left shunt/ Inadequate oxygenation in lungs)
Lips/oral mucosa: Pallor
Teeth: Dental Caries
Palate: High arch palate (Marfan’s)
Conjunctival injection and gum hypertrophy = chronic cyanosis
signs of respiratory distress (grunting and working of ala nasai)
Neck
JVP: Only in older children: Right heart failure, fluid overload), Neck veins (Turn the neck to your side & look to the other side)
Suprasternal notch: thrill in aortic stenosis
·
Inspection chest
· Scars (Raise arms up)
· Precordial bulge
· Visible pulsations
· Dilated veins
·
Palpation chest
· Apex (Both hands on the chest then, count the rib spaces & point to the apex)
- Apex beat: Look for apex beat first. (Look on the right side also, in case it is
dextrocardia). If you can see, point to it. If not seen, feel for it, then count and identify
position. After that, feel for thrills, and the right parasternal heave (with the dorsal aspect of
your palm).
· Thrill (in 4 areas & timing)
· Parasternal heave (lift)
· Palpable heart sound
·
Percussion chest
· Upper border of the liver (if there is hepatomegaly)
Auscultation
. Mitral area (Apex area) --> Tricuspid area (LLSE) --> Pulmonary area (LUSE) --> Aortic area (RUSE)
(Use the Bell for apex only & diaphragm for other areas)
· Back "Below & in between scapula". Neck if there is murmur at RUSE
· Murmur (comment on 6 items)………… Timing (hand on pulse), character, site, radiation, grade & changeable
· Lung bases for crackles
.Comment (Heart sounds, splitting S2, added sounds & murmur)
Cover the child and collect your thoughts
Thanks to the caregiver& turn to the examiner.
Look at the Examiner confidently in his or her eyes & speak loudly, clearly and confidently
Summarize your findings & suggest further actions.
Suggest the provisional diagnosis or at least the closely related differential diagnosis
Listen carefully to the examiner’s questions and respond appropriately.
Listen to Heart sound from MRCPCH 2009 Website; click here
·
At the end
I would like to complete my cardiovascular examination by:
1. Feeling for hepatomegaly
2. Feeling for femoral pulses and looking for scars on the inguinal area for cardiac catheterization/
arterial lines
3. Measure blood pressure (4 limbs if suspect coarctation) and oxygen saturation (if not mentioned earlier )
4. Measure height and weight and plot on growth chart appropriate for age and sex
5. Feeling for peripheral and sacral oedema
6. Auscultate lung bases (if not done earlier)
7. Offer to look at ECG & CXR
How to present
I examined Peter, a 7-year-old boy who looks well-grown for his age and I would like to plot his height and weight on a growth chart.
He is pink and not in respiratory distress. There are no dysmorphic features or finger clubbing. There are no scars on his chest. There is a palpable thrill at his suprasternal notch. He has a grade 3/6 ejection systolic murmur at right upper sternal edge radiating to carotid area.
He has left ventricular outflow obstruction such as aortic stenosis.
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