A history of a heart murmur is important, but many wellchildren have an innocent murmur at some time in their lives. Other cardiac symptoms include cyanosis, palpitations, chest pain, syncope, and near-syncope. A review ofsystems assesses for possible systemic diseases or congenitalmalformation syndromes that may cause cardiac abnormalities (Tables 139-1 and 139-2). Current and past medication use as well as history of drug use, is important. Family history should be reviewed for hereditary diseases, early atherosclerotic heart disease, congenital heart disease, suddenunexplained deaths, thrombophilia, rheumatic fever, hypertension, and hypercholesterolemia.
A complete cardiovascular examination starts in the supine position and includes evaluation in sitting and standing positions when possible. Inspection is supplemented by palpation and auscultation to provide a complete examination.
The examination starts with vital signs. The normal heart rate varies with age and activity. Newborn resting heart rates are approximately 120 beats/minute, slightly higher in infants 3 to 6 months of age and then gradually declining through adolescence to near 80 beats/minute. The range of normal for any given age is approximately 30 beats/minute above or below the average. Tachycardia may be a manifestation of anemia, dehydration, shock, heart failure, or dysrhythmia. Bradycardia can be a normal finding in patients with high vagal tone (athletes), but may be a manifestation of atrioventricular block. The respiratory rate of infants is best assessed while the infant is quiet. Respiratory rate may be increased when there is a left-to-right shunt or pulmonary venous congestion.
Normal blood pressure also varies with age. A properly sized cuff should have a bladder width that is at least 90% and a length that is 80% to 100% of the arm circumference. Initially, blood pressure in the right arm is measured. If elevated, measurements in the left arm and legs are indicated to evaluate for possible coarctation of the aorta. The pulse pressure is determined by subtracting the diastolic pressure from the systolic pressure. It is normally below 50 mm Hg or half the systolic pressure, whichever is less. A wide pulse pressure
Hunter-Hurler syndrome Valvular insufficiency, heart failure, hypertension Duchenne dystrophy Cardiomyopathy, heart failure Pompe disease Short PR interval, cardiomegaly, heart failure, arrhythmias Kawasaki disease Coronary artery aneurysm, thrombosis, myocardial infarction, myocarditis Marfan syndrome Aortic and mitral insufficiency,
Systemic lupus Pericarditis, Libman-Sacks erythematosus endocarditis, congenital AV block
Lyme disease Arrhythmias, myocarditis, heart failure Graves disease Tachycardia, arrhythmias, heart failure (hyperthyroidism)
Tuberous sclerosis Cardiac rhabdomyoma Neurofibromatosis Pulmonic stenosis, coarctation of aorta
AV, atrioventricular.
Trisomy 21 (Down syndrome) Endocardial cushion defect, VSD, ASD, PDA
Trisomy 18 VSD, ASD, PDA, PS
Trisomy 13 VSD, ASD, PDA, dextrocardia
XO (Turner syndrome) Coarctation of aorta, aortic stenosis
CHARGE association TOF, aortic arch and conotruncal (coloboma, heart, atresia anomalies* choanae, retardation, genital and ear anomalies) 22q11 (DiGeorge) syndrome Aortic arch anomalies, conotruncal anomalies*
VACTERL association† VSD (vertebral, anal, cardiac, tracheoesophageal, radial, renal, limb anomalies)