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For the cardiovascular system, a thorough history should be performed at 2 levels: the general review of systems at all well-child and illness visits and a more comprehensive history when a cardiovascular disorder is suspected.

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In infants and younger children, review of feeding and respiration may point to a cardiovascular disorder. Feeding is the stress test of infancy. Rapid breathing or retractions while feeding or failure to gain weight may indicate cardiac disease. In older children, exercise intolerance, light-headedness, syncope, or chest pain may suggest an underlying cardiac abnormality. All these symptoms, however, are common in the general population, and further history, physical examination, and laboratory tests are frequently necessary to determine the cause.

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If the patient’s presentation, screening history, or physical examination suggest a possible cardiovascular disorder, a more detailed cardiovascular history is warranted. Examples include the critically ill patient with shock or respiratory distress, the preschool or adolescent child with a newly detected heart murmur, and the child complaining of chest pain, exercise intolerance, palpitations, or syncope. A more detailed history should include any issues during the pregnancy and neonatal period, growth and development during early childhood, and family history, as well as the current complaint. Specific areas include the following:

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  • pregnancy and neonatal history (eg, maternal diabetes or systemic lupus erythematosus, maternal medications, need for supplemental oxygen after birth, and neonatal illnesses)
  • infancy (eg, feeding difficulties, failure to thrive, cyanosis, and respiratory distress)
  • children and adolescents (eg, lack of peer-appropriate exercise tolerance, syncope, chest pain)
  • family history (eg, congenital heart abnormalities in close relatives, sudden death or premature “heart attacks,” chromosomal abnormalities in parents or other family members).

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Physical Examination

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The cardiovascular examination should be systematic. Cardiac disorders are seldom missed because the examiner could not distinguish a grade 2 from a grade 3 murmur, but rather because a major portion of the examination was overlooked (eg, failure to measure blood pressure or confirm the presence of pulses in the lower extremity in patients with coarctation of the aorta).1 What follows is an outline of a systematic examination with reference to the particular questions to be considered at each point.

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  • Vital signs. Are the weight, height, head circumference, heart rate, and blood pressure age-appropriate?
  • Head and neck. Is there cyanosis, dental caries, jugular venous distention, evidence of genetic syndrome?
  • Chest. Is there a skeletal deformity (pectus carinatum, pectus excavatum, straight back, asymmetric thorax), stridor, retractions, wheezes, rales?
  • Precordium and heart. Are there palpable heaves or thrills murmurs or extra heart sounds? What are the sites and intensity of first and second heart sounds (see below)?
  • Abdomen. Is the liver or spleen enlarged or are there ascites? Is abdominal situs normal?
  • Extremities. Are the pulses normal in all extremities, or is there cyanosis, clubbing, or edema?

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Examination of the Heart

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Examination of the heart should be done ...

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