Pediatric Cardiovascular Examination

2016
1.On approaching a child:
Monitoring (oxygen saturation probe), Supplemental oxygen
Nutritional status:
well-nourished or undernourished
I would like to plot his height and weight on a growth chart
Work of breathing: acting ala nasi, Respiratory rate.
Age
Normal
Tachypnoea
Neonate
30-50
>60
Infants
20-30
>50
Young children
20-30
>40
Older children
15-20
>30
Colour:
Pallor (Anaemia): Conjunctive, oral mucosa
Central cyanosis
(Cyanotic CHD/ Inadequate oxygenation in lungs)
Tongue, lips, mucous membrane.
Becomes clinically apparent when saturations are
below
85%
You should say that the patient is not clinically
cyanosed unless they are very obviously blue.
Jaundice (Congestive cardiac failure Hepatic congestion)
Sclera
Polycythaemia (Cyanotic heart disease Increased
haematocrit)
Periorbital odema

Dysmorphism:

Genetic Syndrome Commonly Associated Cardiac Defect

Down syndrome AVSD

Turner syndrome Bicuspid aortic valve, coarctation
Noonan syndrome Dysplastic pulmonic valve, HCM
Williams syndrome Supravalval aortic stenosis, PPS.
Maternal rubella PDA, PPS

2.Hand and Finger

Clubbing:
present after long-standing arterial desaturation (over 6
months)
Is often associated with severe cyanotic congenital heart

disease.
Peripheral cyanosis
Splinter haemorrhages
Capillary refill
Janeway lesion
Osler nodes
Bony abnormalities: Absent Radii

3. Pulse- Radial and brachial, femoral.

pulse rate
Increased pulse rate may indicate excitement, fever, CHF, or
arrhythmia.
Bradycardia may mean heart block, hypothryrodism,
hypothermia.
volume of the pulses
Weak, thready pulses are found in cardiac failure or
circulatory shock.
Bounding pulses
Rhythm (regular, Irregularity)
Radio-femoral delay

Normal resting pulse rate in children

Age
<1 year
2-5 years
5-12 years

Beats/min
110-160
95-140
80-120

>12 years

60-100

A femoral pulse that is absent or weak, or that is delayed in

comparison with the brachial pulse, suggests coarctation of the aorta.
Note: if cannot feel pulses say pulses are difficult to feel
4. Blood pressure
should be measured in the arms as well as in the legs,
Mercury sphygmomanometer with a cuff that covers
approximately two thirds of the upper part of the arm or leg
may be used for blood pressure measurement.
Initially, blood pressure in the right arm is measured. If
elevated, measurements in the left arm and leg are
indicated to evaluate for possible coarctation of the aorta.
A cuff that is too small results in falsely high readings,
whereas a cuff that is too large records slightly decreased
pressurethe
The pressure recorded in the legs is about 10 mm Hg higher
than that in the arms.

Pericardium examination
Inspection:
Chest wall deformity
Anterior bulge chest (cardiomegaly)
Asymmetry
Pigeon chest (pectus carinatum)
Pectus excavatum (funnel chest)

 Visible pulsation.
Scars: Back scars, Front scars
Right thoracotomy scar
Midline sternotomy scar
Left thoracotomy scar
Chest drain scars
Cautery marks.
Recessions (SSR, ICR, SCR)
Harrison's groove (sulcus), a line of depression in the bottom of
the rib cage along the attachment of the diaphragm
Dilated chest veins
SVC Obstruction ( Mediastinal mass),
IVC obstruction ( Thoracic/ abd mass)

Palpation:
Hyperdynamic precordium:
Volume load: a large left-to-right shunt,
Normal in a thin patient
Apex beat:
the apical impulse is in the fourth intercostal space
midclavicular line in older children becomes in 5th ICS.
Displaced to left: Cardiomegaly, pectus excavatum, scoliosis
Displaced to right: Congenital dextrocardia, Left
diaphragmatic hernia,Collapsed lung on right, Left pleural
effusion, Left pneumothorax
Left parasternal heave RVH
Thrills are the palpable of murmurs
suprasternal notch and neck for aortic bruits, which may
indicate the presence of aortic stenosis or, when faint.
Pulmonary area. PS
left lower sternal border and
Apical Palpable murmur-Organic , > 3grade
hepatomegaly. the cardinal sign of right heart failure in the
infant and child.

Auscultation:
1. Auscultate areas:
Mitral area (Apex area)
Tricuspid area (LLSE)
Pulmonary area (LUSE)
Aortic area (RUSE)
2. Also auscultate
Axillary area (if there is murmur at Apex or LUSE)
Back (If there is murmur at LUSE)
Neck (if there is murmur at RUSE)
3. Base of lungs for inspiratory crepitation in cardiac failure

4. Auscultators sounds
Heart sounds
Added sound
Heart Murmurs
Heart Sound
First heart sound- Mitral and Tricuspid valve closure-S1
best heard at the apex
Second heart sound - Aortic then Pulmonary valve closure
S2 should be evaluated at the upper left and right sternal
borders
Added sound
Third heart sound - Rapid diastolic filling-S3
Fourth heart sound Atrial contraction against poorly
compliant ventricle-S4
Opening snaps, Ejection click, Pericardial rub Murmur
Heart Murmurs
Murmur: turbulence of blood flow
Normal flow across a narrowed valve or septal defect
Increased flow across a normal valve in hyperdynamic
states; anemia.
Types:
Systolic murmurs
Ejection systolic murmur (PS, AS)

 Pansystolic murmur (VSD, MR, TR)

Diastolic murmurs
Early diastolic murmurs (Aortic regurgitation ,pul
reg)
mid diastolic murmurs (mitral stenosis)
Continuous murmurs (Patent Ductus Arteriosus
,BTshunt)

Describing a heart murmur:

1) Timing.
2) Location of maximum intensity
3) Radiation Intensity of the murmur & Direction of blood
flow Axilla (MR), Clavicle(PDA), Neck(AS)
4) Intensity graded on a 6 point scale
Grade 1 = very faint, difficult to hear
Grade 2 = quiet but heard immediately
Grade 3 = loud without thrill
Grade 4 = loud with thril
Grade 5 = heard with stethoscope partly off the chest
Grade 6 = very loud and audible with the stethoscope off the
chest:

CVS exam
Greeting, Introduce
General Approach

Preicordium Examination

Nutrional status
Growth Parameter

Inspection

Monitoring
Working of breath
Dysmorphisim
Colour
Vital signs:
Pulse rate
Respiratory rate
Blood pressure
Clubbing
Capillary refilling time
Osler Nodules, Janway lesion
Splinter heamorage

Chest deformity
Visible Pulsation
Scars
Dilated Veins
Recesions

Palpation
Apex beat
Heave
THrill
Hepatomegaly

Auscultation
Heart sound
Added Sound
Heart Murmur
Base of lung