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.
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.
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:
- 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).
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.
- 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?
of the Heart
Examination of the heart should ...