Pediatrics
Module -2- 2018-2019
Chest and CVS Prof. Yusra AR Mahmood
Chest :
Notes:
• the sequences of examination depends on the cooperation of the child.
• Auscultation of chest for normal and abnormal sounds is possible even with a
Crying child.
• Wait for each inspiration during the cry to hear all sounds except for wheeze.
Inspection:
• Nature of respiration ( rate, depth ).
• Size,Shape and symmetry of chest
Size: use tape measure to measure the chest circumference( CC) at the level
of xiphisternum , it is 33cm at birth, 48cm at one year, 52cm at 3years.
Before one year of age ; CC is smaller than OFC.
After one year of age ; CC larger than OFC.
Shape: in infant the chest appear round i.e. AP diameter= transverse
diameter. At 2 years of age the chest is oval, i.e. transverse diameter larger
than AP diameter.
• Type of respiration:
In young infant the respiration is abdominal.
After 4-5 years most of the respiration is due to intercostal M.
Reduced total excursion of the chest suggests pleural irritation.
Grunting suggest painful condition.
• Symmetry:
Unequal movement of chest suggests unilateral lung pathology e.g. foreign
body
Paradoxical respiration (= clinically manifested as collapse of chest during
inspiration and the abdomen becomes prominent during expiration),
indicates diaphragmatic paralysis, poliomyelitis, neuromuscular disorders.
• Using accessory M for respiration
In upper airway obstruction( croup, diphtheria) : suprasternal retraction
In lower airway obstruction(asthma): retraction is seen in lower intercostal
space.
Palpation
• Tenderness.
• Localized mass, swelling.(texture, temperature, tension, tenderness)
Sternal tenderness suggests leukemia.
• Trachea : with the index and ring finger feel the position of trachea.
Slight deviation of trachea to the right is normal.
Exclude scoliosis.
• Cardiac impulse: locate the point of maximum cardiac impulse.
5th intercostal space on or just inside midclavicular line on left side.
• Chest expansion: The palms are laid on the chest symmetrically on the
posterior surface of the chest with the thumbs touching each other in the
midline anteriorly.
• Vocal fremitus. During crying , or ask child to say one or 99.
Palpate both halves of chest by the palm. Compare both sides.
Percussion:
Includes:
• Character ( resonant , hyperresonant, dull, stony dull)
• Liver dullness level.
Use indirect two fingers technique.
Percuss supraclavicular , infraclavicularm, mammary, inframammary regions.
In the back: suprascapular, interscapular, infrascapular.
Compare both sides.
Start at the top proceeds downward covering the front, sides, back of the chest.
One expect dullness over the heart
Auscultation :
• Character of breath sounds( vesicular, bronchial, bronchovesicular)
Vesicular B heard all over the chest
Bronchial B heard normally over the trachea only, in infant at T2 level
posteriorly.
• Added sounds (wheeze and crepitation, plural rub).
Wheeze and rhonchi : inspiratory as in croup, expiratory as in asthma.
Crackles includes: crepitation and rales.
• Vocal resonance. ask the child to say one or 99 .heard by auscultation.
Heart :
Inspection:
• Precordium
• Character and rhythem of cardiac impulse
• Localization of the apex beat.
Palpation ;
• Localization of apex beat and its character
• Thrills
Percussion:
• For the heart boundaries
Auscultation:
• Character of S1and S2.
• Presence or absence of splitting S2, opening snap, ejection clicks, gallop
rhythm.
• Added sounds:
o Murmurs:
§ Timing : systolic , diastolic.
§ Character
§ Maximum intensity
§ Radiation.
o Pericardial rub.
Inspection :
Undress the patient
Inspect for visible pulsation:
right side pulsation ………….dextrocardia
intercostal pulsation posteriorly ……………. Collaterals in case of coarctation
epigastric pulsation….. right ventricular hypertrophy
normally in thin children
apex :
visible in 5th ICS on MCL.
Palpation:
Palpate S in the apex, S2 in p area
Thrill: timing, location
Percussion: for cardiac size,
Auscultation:
Auscultate the four area . apex, triuspid, along the left sternal border ,the pulmonary
then aortic area, the back.
S1 : intensity increases in case of fever, mitral stenosis, thyrotoxicosis
S2 Splitting: is normal , best heard at p area.
S3 ; heard during the diastole over the apex
It is not abnormal in pediatrics
Gallop rhythm: due to presence of S3 or due to serious heart problems
Murmurs
Location :
M-area: MS, MR , Functional
P- area : PS, ASD, pulmonary hypertension.
Left sternal boarder : VSD , AR, PR
A- Area,:AS , COA,
T- area: T R , TS
Left second intercostal space : PDA
Timing : systolic or diastolic in relation to S1 and S2
Type:
Pansystolic M : VSD, MR
Early systolic M (ejection systolic): PS, AS , functional M.
Midsystolic ( flow murmur) : functional murmur, AS, PS, ASD
Diastolic M always organic.
Early diastolic M : PR, AR
Mid diastolic M: MS.
Intensity: Grade 1 to Grade 6.
