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Overall assessment of cardiac function involves a comprehensive evaluation of pulse, blood pressure, respiratory function and general physical growth and development. The doctor must be familiar with the anatomy and physiology of the normal heart in order to properly evaluate the findings. The Apex is located at the left mid-clavicular line and fifth intercostals space or mitrial area. The heart of the infant is more horizontally positioned; therefore, the apex is higher (third to fourth intercostals space) and to the left of the mid-clavicular line. The apical impulse, or point of maximum impulse, is normally located at the apex. Inspection While examining the chest, any obvious bulging is noted, especially on the left side, which may indicate cardiac enlargement. This is best done by observing the child sitting and looking at the anterior chest wall from an angle, comparing both sides of the rib cage to each other.
Normally they should be symmetric in children with thin chest walls, the point of maximum impulse, or apical pulse, is sometimes apparent as a pulsation. Noting the location of the impulse may give some indication of the size and positioning of the heart, especially if it deviates from the expected apical site. Since comprehensive evaluation of cardiac function is not limited to the heart, the doctor also considers other findings, such as presence of all pulses (especially the femoral pulses), distended neck veins, peripheral cyanosis, edema, blood pressure, and respiratory status. Palpation is useful in determining the size of the heart by feeling for the point of maximum impulse, which ordinarily corresponds to the apex. The apex is usually at a lower interspace and more lateral in a child with cardiac enlargement. The apex is felt by placing the fingertips or the palmer aspect of the fingers and hand at the fifth intercostals space and left mid-clavicular line.
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