---

Percussion in CVS Examination - Pediatrics: What to Write in Interpretation

---

What You Are Percussing For

---

Two Areas of Dullness to Know

Relative cardiac dullness corresponds to the true cardiac border and is the more clinically meaningful measurement.

---

Technique (Brief)

• Percuss from resonant (lung) to dull (heart) - lateral to medial
• Right border: Percuss 4th intercostal space, right side, from lateral to medial - note where resonance becomes dull
• Left border: Percuss obliquely in 3rd, 4th, and 5th intercostal spaces on the left - from lateral to medial
• Upper border: percuss vertically downward in the parasternal line

---

Normal Cardiac Border Landmarks (Adults; modified for children below)

• Infants/toddlers: Apex beat at 4th ICS, mid-clavicular line - left border of dullness should correspond to this
• Children (>5 years): Apex beat at 5th ICS, mid-clavicular line - same as adult

---

What to Write in the Interpretation

"On percussion of the precordium, area of cardiac dullness is normal in extent. Right border of cardiac dullness is at the right sternal edge. Left border of cardiac dullness corresponds to the apex beat at the [4th/5th] intercostal space, mid-clavicular line. No extension of dullness beyond the apex beat. Percussion note is resonant over both lung fields bilaterally."

---

---

Key Points to Remember for the Exam

1. Percussion is not routinely used in pediatric CVS - its main use is suspecting pericardial effusion, where dullness extends beyond the apex beat
2. Always correlate percussion findings with the apex beat - if the area of dullness extends beyond where you palpated the apex, suspect pericardial effusion
3. In cardiomegaly, dullness and apex beat shift together laterally and downward
4. In pneumothorax, the percussion note becomes hyperresonant over the affected side and you may lose cardiac dullness on that side
5. Percussion findings must always be interpreted alongside palpation, auscultation, and the overall clinical picture

---

Sample Statement for an Academic Case Write-up

"Percussion of the precordium reveals the right border of cardiac dullness at the right sternal edge and left border at the apex beat in the [4th/5th] ICS mid-clavicular line, appropriate for age. No abnormal extension of dullness is noted. Percussion note is resonant over both lung fields. No evidence of pericardial effusion on percussion."

"On percussion, dullness extends beyond the palpated apex beat. The area of cardiac dullness appears increased, extending to the [X] ICS [X] cm lateral to the mid-clavicular line. This is consistent with pericardial effusion. Dullness was also noted over bilateral lung bases, suggestive of basal pleural effusion in the context of heart failure."

---

---

PULSE - Complete Guide (Physiology + Clinical Examination)

---

1. DEFINITION

---

2. PHYSIOLOGY

• With each ventricular systole, blood is ejected into the aorta, creating a pressure wave
• This wave is transmitted along arterial walls faster than actual blood movement
• The wave is influenced by: stroke volume, arterial compliance, peripheral vascular resistance, and heart rate
• In children, cardiac output is primarily rate-dependent (unlike adults where it is stroke volume-dependent). This is why tachycardia is the earliest and most important sign of cardiovascular compromise in children

---

3. SITES OF PALPATION (in order of clinical use)

Pediatric note: In infants, use the brachial artery (larger calibre, closer to central arteries) for volume and character. In neonates and unstable children, use central pulses (femoral, brachial) rather than peripheral ones. In newborns, direct auscultation at the apex is the most accurate method for heart rate.

---

4. WHAT TO ASSESS - THE 8 PROPERTIES OF PULSE

---

4.1 Rate

• Fever (most common in children)
• Anemia
• Thyrotoxicosis
• Sepsis (early)
• Hypovolemia
• Pain/anxiety
• Sympathomimetic drugs (cocaine, ephedrine)
• Heart failure

• Athletes (physiological)
• Hypothyroidism / myxedema coma
• Hypothermia
• Raised intracranial pressure (Cushing's triad)
• Beta-blockers, digoxin
• Complete heart block
• Typhoid fever (relative bradycardia despite high fever)

---

4.2 Rhythm

• Sinus arrhythmia: Pulse increases with inspiration, slows with expiration - physiological and normal, especially common in children and adolescents
• Pulse deficit: Apical rate > radial rate - seen in AF; the difference is the pulse deficit, and greater deficit = more severe disease

---

4.3 Volume (Amplitude)

---

4.4 Character (Waveform)

Pulsus paradoxus mechanism: On inspiration, intrathoracic pressure falls → increased venous return to RV → RV expands → interventricular septum shifts left → reduces LV filling → reduced LV stroke volume → fall in BP. In tamponade, pericardial fluid prevents normal compensatory expansion of RV, making this exaggerated. A fall >25 mmHg is strongly correlated with hemodynamic compromise from tamponade.

---

4.5 Tension (Condition of the Vessel Wall)

• Reflects arterial wall stiffness
• Assess by compressing the radial artery proximally and feeling distally
• Hard, tortuous, "pipe-stem" vessel = arteriosclerosis (elderly)
• Not commonly formally assessed in pediatrics

---

4.6 Equality (Both Sides)

• Compare both radial pulses simultaneously - inequality suggests subclavian artery obstruction, aortic dissection
• Compare radial and femoral simultaneously:
  • Radiofemoral delay = femoral pulse felt after radial = Coarctation of the aorta (important in pediatrics)
  • Normally both are simultaneous

---

4.7 Radioradial Delay

• Right radial felt before left radial
• Causes: right-sided aortic arch, thoracic aortic aneurysm, coarctation proximal to left subclavian

---

4.8 Symmetry (Upper vs Lower Limb)

• In coarctation of aorta: brachial > femoral in volume; delay present
• In normal children: femoral should be felt simultaneously and of equal volume to radial/brachial
• Absent or weak femoral pulses in an infant = coarctation of aorta until proven otherwise

---

5. PULSE PRESSURE

---

6. SPECIAL CLINICAL SIGNS RELATED TO PULSE (Eponymous)

---

7. HOW TO WRITE PULSE IN A CLINICAL CASE (Pediatric CVS Exam)

"Pulse is 88 beats per minute, regular in rate and rhythm, good volume, normal character, no radioradial or radiofemoral delay. Femoral pulses are palpable and equal to upper limb pulses bilaterally. Vessel wall is normal."

• Coarctation: "Pulse is 96 bpm, regular. Femoral pulses are weak and delayed compared to the radial pulse bilaterally, consistent with radiofemoral delay. Suggestive of coarctation of the aorta."
• Aortic regurgitation / large PDA: "Pulse is collapsing in character (waterhammer), high volume, best appreciated with arm elevation. Pulse pressure is wide."
• Tamponade: "Pulsus paradoxus noted - pulse volume decreases markedly on inspiration, with estimated drop >10 mmHg."
• Heart failure: "Pulse is 140 bpm, regular, low volume, thready in character. Pulsus alternans noted with alternating strong and weak beats."

---

8. QUICK SUMMARY TABLE

---

---

UMN vs LMN Lesions: Cranial Nerve Examination Findings

---

FOUNDATIONAL CONCEPT: WHY CRANIAL NERVES BEHAVE DIFFERENTLY

Nearly all cranial nerve motor nuclei receive BILATERAL corticobulbar innervation. This means a unilateral UMN lesion will NOT cause significant weakness for most cranial nerves - because the intact contralateral hemisphere still supplies the same nucleus.

• CN VII - Lower face division only
• CN XII - Hypoglossal nucleus (partially unilateral)

---

GENERAL UMN vs LMN COMPARISON TABLE

---

CRANIAL NERVE-BY-CRANIAL NERVE BREAKDOWN

---

CN V - TRIGEMINAL NERVE (Motor: Muscles of Mastication)

• Therefore: Unilateral UMN lesion usually produces no significant jaw weakness
• Bilateral UMN lesion (pseudobulbar palsy): jaw does not open, jaw jerk exaggerated

Unilateral LMN CN V: On opening the mouth, the jaw deviates to the side of the lesion because the lateral pterygoid on the affected side is weak.

---

CN VII - FACIAL NERVE ⭐ (Most Important for UMN vs LMN)

• Upper face (forehead, orbicularis oculi) → BILATERAL cortical supply
• Lower face (orbicularis oris, buccinator, platysma) → UNILATERAL (contralateral) supply

"UMN = Forehead Spared, Lower face affected, Contralateral" "LMN = Whole face affected, Ipsilateral, Forehead involved"

• UMN CN VII: Stroke (internal capsule/genu), cerebral infarct
• LMN CN VII: Bell's palsy, Ramsay-Hunt syndrome, parotid tumor, skull base fracture

• Afferent (CN V) is intact - patient feels the touch on both sides
• Efferent (CN VII) is affected - blink is reduced/absent on the side of LMN lesion
• The consensual response on the affected side is stronger when testing the opposite eye (because the unaffected contralateral CN VII drives the blink)

---

CN IX (Glossopharyngeal) & CN X (Vagus Nerve)

• Unilateral UMN lesion: usually no significant deficit (bilateral supply compensates)
• Bilateral UMN lesion (pseudobulbar palsy): severe dysarthria, dysphagia

• Uvula deviates toward normal side (away from the LMN lesion) - the intact side of the palate pulls it across
• "Uvula flees from the lesion"

---

CN XI - ACCESSORY NERVE (Sternocleidomastoid & Trapezius)

Why SCM is ipsilateral in UMN: Due to the double decussation in the brainstem, a unilateral cortical infarct causes ipsilateral SCM weakness and contralateral trapezius weakness. The head is turned toward the side of the lesion (away from the paralyzed body side) in a stroke - because the contralateral SCM is intact and turns the head toward the lesion.

• SCM: Ask patient to turn head against resistance - weakness on the tested side = that SCM is weak
• Trapezius: Ask patient to shrug shoulders against resistance

---

CN XII - HYPOGLOSSAL NERVE ⭐

• Partially analogous to lower face of CN VII - unilateral UMN lesion CAN produce deficit

UMN - Tongue deviates AWAY from lesion LMN - Tongue deviates TOWARD the lesion

---

BULBAR vs PSEUDOBULBAR PALSY - THE CLINICAL SYNDROME

---

QUICK REVISION SUMMARY TABLE

---