Pediatric Heart Examination

Every examination of the heart begins by inspecting the thorax. Thoracic asymmetries must be noted. The chest may sometimes show a bulge over the heart which indicates cardiomegaly. During palpation the first thing to locate is the point of maximum impulse which is normally found in the left medoclavicular line. In babies and young children the point of maximum impulse is in the fourth intercostal space. In older children it is between the fourth and fifth intercostal space. During palpation assess if the maximum impulse is raised or widened or too far to the left.

These findings would indicate left ventricular hypertrophy. A raise on the lower left sternal border may indicate right ventricular hyperactivity and hypertrophy. Sometimes a palpable cardiac thrill indicates circulatory pathology. The thrill should also be sought in the suprasternal notch. With young children cardiac percussion is hardly ever performed. The heart is auscultated in the following order. Second right and left intercostal space. Third left intercostal space. Herbs point. Fourth left intercostal space. Lower left sternum border. As well as over the heart apex and in special cases the fourth right

intercostal space. This illustration shows the relationship between the points of auscultation, the skeleton, and the heart valves. Murmers which originate in the pulmonary valve can best be heard in the second left intercostal space. Murmers radiate from the aortic valve via the aortic arch to the second right intercostal space. Murmers of mitral origin can be heard at herbs point and at the heart apex. A ventricular septal defect can be heard best at the lower left sternum border and at herbs point. Murmers which originate at the tricuspid valve radiate

peristernally to the lower right sternal border. During auscultation note the following points. Heart rate, rhythm, that is the regularity of the heartbeat, quality of the heart sounds, and the presence of additional heart sounds, murmurs or clicks. The heart rate changes with age. In the first year of life the heart rate is about 140 beats per minute. In the second year 120. In the fourth 100, in the eighth 90. Towards the end of puberty the heart rate approaches that of an adult. When listening to heart sounds we note their intensity.

Possible splitting. Whether there are additional sounds in the form of a third or fourth heart sound and clicks. Murmers can be diastolic or systolic. Can you hear this holocystolic murmur? In addition to the duration of a murmur we also judge its loudness on a scale of one to six. We further describe the quality of the murmur, that is whether it is soft or rough, the point of maximum intensity, as well as possible radiation to other areas, especially the back and the carotid arteries.