CHEST EXAMINATION OF INFANT OR CHILD

CHEST EXAMINATION OF INFANT OR CHILD

The size, shape and symmetry are carefully examined. A special note should be made about presence of any retraction (suprasternal, intercostal), rachitic rosary, pigeon chest deformity, funnel chest, gynecomastia, etc.

In examination of lungs, it is important to note the type of breathing, dyspnea, chest expansion, cough, vocal dullness, percussion note, breath sounds, crepitations, wheeze, etc. Remember that in young children, breathing is mainly abdominal.

We should examine the heart for location of apex beat, its intensity, precordial bulging, thrills, size, shape, sounds, murmurs, friction, rub, etc. We should be examined while the child is erect, recumbent and turned to left. Also that extrasystoles may he heard in many normal children. Likewise, sinus arrhythmia may be a normal finding in childhood. Cardiac examination must in particular be very careful, nothing the presence of a precordial bulge, substernal thrust, apical heave or a hyperdynamic precordium, thrills (both systolic and diastolic), aortic bruits, etc.

Auscultation of the precordium requires patience, first concentrating on the characteristics of the individual heart sounds and then on the murmurs. An accentuated or loud first heart sound over the mitral area suggests tachycardia, hyperkinetic heart syndrome, hyperthyroidism or mitral stenosis. In mitral regurgitation and myocarditis, the first heart sound over the mitral area is particularly faint. In tricuspid atresia, the first heart sound over the tricuspid area is accentuated or loud. The second sound is split little beyond the peak. of inspiration; it closes with expiration. A wide splitting is encountered in pulmonary stenosis, tetralogy of Fallot, atrial septal defect, total anomalous venous return and Ebstein anomaly. A narrow splitting points to pulmonary hypertension. The third sound is best heard with the bell at the apex in middiastole, especially if the child assumes a left lateral position. It is of significance in the presence of signs of congestive cardiac failure and tachycardia in which situation it may merge with the fourth sound. The latter, coinciding with atrial contraction, may be heart a little before the first sound in late diastole. The phenomenon of poor compliance of the ventricle with an exaggeration of the normal third sound associated with ventricular filling is termed “gallop rhythm”.

After the heart sounds, attention should be focused on click. Aortic systolic clicks, best heard at the left lower sternal border occur, in aortic dilation as in aortic stenosis, tetralogy of Fallot, or truncus arteriosus. Pulmonary ejection clicks, best heard at the left midsternal border, occur in pulmonary stenosis. In prolapse of the mitral valve, a mid-systolic click precedes a late systolic murmur at the apex.

Murmurs need to be described as to their timing, intensity, pitch, area of highest intensity and transmission.

Whether a particular murmur is just functional (innocent with no significance) or has a pathological origin(congenital heart disease) must be decided. Murmurs are audible sounds arising from the flow of blood through blood vessels, valves or heart chambers evincing turbulence. In children, because of closeness of the heart to the thin chest wall, murmurs are relatively more easily heard. As a rule, narrower the blood vessel or opening, or higher the turbulence of flow, louder is the murmur. Murmurs are usually classified as systolic, diastolic, and continuous.

Systolic murmurs may be ejection, pansystolic or late systolic.  An ejection systolic murmur rises to a crescendo in midsystole. It is, as a rule, coarse. Examples of such murmur are aortic stenosis, aortic coarctation, pulmonary stenosis and atrial septal defect. A pansystolic murmur occurs all through systole. It is caused by flow of blood through a septal defect(ventricular septal defect) or an incompetent mitral or tricuspid valve (mitral incompetence), tricuspid incompetence, or a patent ductus arteriosus. A late systolic murmur is heard well beyond the first sound and stretches to the end of systolic phase (mitral valve prolapse). According to intensity, systolic murmurs are categorized in to 6 grades.

Six grades of systolic murmurs (Keek’s classification)

Grade    Characteristics

1.                        Faintest, requiring very careful auscultation in noise free environments       

               (consultant’s murmur); innocent

2.                        Soft though slightly louder; usually innocent

3.                        Moderately loud without a thrill; may be innocent or organic

4.                        Loud, accompanied by a thrill; always organic

5.                        Very loud, accompanied by a thrill; still needs stethoscope in contact with chest; always organic

6.                        Loudest possible, accompanied by a thrill heard with stethoscope not necessarily in contact with the chest; always organic.

Diastolic Murmurs may be

1.      High-pitched blowing along the left sternal border, indicating aortic insufficiency or pulmonary valve insufficiency.

2.      Early short, lower-pitched protodiastolic along the left mid and upper sternal border, indicating pulmonary valve insufficiency or after repair of pulmonary outflow tract in such conditions as tetralogy of Fallot.

3.      Early diastolic at the left mid and lower sternal border, indicating atrial septal defect or atrial valvular stenosis.

4.      Rumbling middiastolic at the apex after the third heart sound, indicating large right to left shunt or mitral insufficiency.

5.      Long diastolic rumbling murmur at the apex with accentuation at the end of diastole (presystolic), indicating anatomical mitral stenosis.

A continuous murmur (machinery murmur)is a systolic murmur, beast heard over the second and third left parasternal spaces, that extends in to diastole. It indicates a patent ductus arteriosus. It must be differentiated from a pericardial friction rub, as also from a venous hum.

Remember, over 30% children may have a murmur without significant hemodynamic abnormalities. Typically, the so-called “innocent murmur” is heard in the age group 3 to 7 years, occurs during ejection, is musical and brief, is attenuated in the sitting position, and is intensified by pyrexia, excitement and exercise. As the child grows, such a murmur shows a tendency to be less well heard and may regress fully.

It is of help to apply the time-honored Nada’s criteria for presence of heart disease in suspected cases.