Examination of the heart involves the skills of inspection, palpation, percussion and auscultation, although the later is the most significant. Overall assessment of cardiac function involves a comprehensive evaluation of pulse, blood pressure, respiratory function and general physical growth and development. The doctor must be familiar with the anatomy and physiology of the normal heart in order to properly evaluate the findings.
The Apex is located at the left mid-clavicular line and fifth intercostals space or mitrial area. The heart of the infant is more horizontally positioned; therefore, the apex is higher (third to fourth intercostals space) and to the left of the mid-clavicular line. The apical impulse, or point of maximum impulse, is normally located at the apex.
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Inspection
While examining the chest, any obvious bulging is noted, especially on the left side, which may indicate cardiac enlargement. This is best done by observing the child sitting and looking at the anterior chest wall from an angle, comparing both sides of the rib cage to each other. Normally they should be symmetric in children with thin chest walls, the point of maximum impulse, or apical pulse, is sometimes apparent as a pulsation. Noting the location of the impulse may give some indication of the size and positioning of the heart, especially if it deviates from the expected apical site.
Since comprehensive evaluation of cardiac function is not limited to the heart, the doctor also considers other findings, such as presence of all pulses (especially the femoral pulses), distended neck veins, peripheral cyanosis, edema, blood pressure, and respiratory status.
Palpation
Palpation is useful in determining the size of the heart by feeling for the point of maximum impulse, which ordinarily corresponds to the apex. The apex is usually at a lower interspace and more lateral in a child with cardiac enlargement. The apex is felt by placing the fingertips or the palmer aspect of the fingers and hand at the fifth intercostals space and left mid-clavicular line.
While feeling for the point of maximum impulse, the doctor notes the presence of vibratory thrills and pericardial friction rubs. Thrills are palpable vibrations most commonly produced by the flow of blood from one chamber of the heart to another through a narrowed or abnormal opening, such as a stenotic valve or a septal defect. They are best felt with the ball of the hand (palmer surface at the base of the fingers) and during expiration. Thrills feel similar to the placing of one's hand on a purring cat.
Pericardial friction rubs are scratchy, high-pitched grating sounds. Similar to pleural friction rubs, except that they are not affected by changes in respiration. This is a useful clue in differentiating the two rubs, because the pleural rub will cease if the child holds his breath, but the pericardial rub will not. Both thrills and rubs are abnormal and must be reported for further evaluation.
Assessing the quality and symmetry of all pulses
Pulse is examined and rate, rhythm, volume and character are noted; alterating, large, swift, dicrotic, intermittent, labile, small, slow, soft, tense, rhythmic, rapid, pulse deficit, pulse flutter, tension of the pulse, full (weak) pulse, comparison with other pulses is important to note radio-femoral delay. Lift the arm to feel the collapsing pulse.
Clinical examination of the heart of a child is quite technical but with close examination and great sensitivity on the Doctor's part, it will not only be easy but very interesting.
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