Paediatric Cardiovascular

Examination
Dr. Ibtesam Ahmed
2016

Please: Greeting
Introduce your self

1. On approaching a child

Monitoring (oxygen saturation probe), Supplemental

oxygen
Periorbital odema

1. On approaching a child
Nutritional status:
well nourished or undernourished.
I would like to plot his height and weight on a growth
chart.

1. On approaching a child
Work of breathing:
Respiratory rate, Signs of Respiratory distress
Respiratory rate in children (breaths/min)

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 mucos

Central cyanosis (Cyanotic CHD/ Inadequate oxygenation in lungs)
clinically apparent when saturations are below 85%

Jaundice (Congestive cardiac failure Hepatic congestion) Sclera

Polycythaemia (Cyanotic heart disease Increased haematocrit)

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. Hands, 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

2. Hands, Finger
Janeway lesion
Osler nodes
Bony abnormalities: Absent Radii
Palmer creases

4. Pulse- Radial and brachial

Pulse rate
Increased pulse rate may indicate: (excitement, fever, CHF, or arrhythmia).
Bradycardia: (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

Beats/min

<1 year

110-160

2-5 years

95-140

5-12 years

80-120

>12 years

60-100

5. Blood pressure
Initially, blood pressure in the right arm is measured.
If elevated, measurements in the left arm and leg.
Proper cuff that covers approximately two thirds of
the upper part of the arm or leg.
A cuff that is too small results in falsely high
readings, whereas a cuff that is too large records
slightly decreased pressure.

 The pressure recorded in the legs is about 10

mm Hg higher than that in the arms.

Pericardium examination
Inspection
Palpation
Auscultation

Inspection

Chest wall deformity

Anterior bulge chest (cardiomegaly).

Asymmetry
Pigeon chest (pectus carinatum)
Pectus excavatum

Inspection

Visible pulsation.
Scars: Back scars, Front scars
Right thoracotomy scar
Midline sternotomy scar
Left thoracotomy scar
Chest drain scars
Cautary marks

Inspection
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 at the midclavicular
line.
After age of 7 years at fifth intercostal space in the midclavicular line
Displaced to left: Cardiomegaly, pectus excavatum, scoliosis
Displaced to right: Congenital dextrocardia, Left diaphragmatic
hernia,Collapsed lung on right, Left pleural effusion, Left pneumothorax

Palpation:
Left parasternal heave RVH
Thrills are the palpable murmurs
suprasternal notch and neck for aortic bruits, which may indicate the
presence of aortic stenosis,
pulmonary area.
Left lower sternal border and
Apical Palpable murmur

hepatomegaly. the cardinal sign of right heart failure in the infant and
child.

Auscultation:
Auscultate areas:
Mitral area (Apex area)
Tricuspid area (LLSE)
Pulmonary area (LUSE)
Aortic area (RUSE)

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)

Base of lungs for inspiratory crepitation in cardiac failure

Heart sounds
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 ventricleS4
Opening snaps, Ejection click,

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; anaemia, PDA

Types:
Systolic murmurs
Ejection systolic murmur (PS, AS)
Pansystolic murmur (VSD, MR, TR)

Diastolic murmurs
Early diastolic murmurs (Aortic regurgitation ,pul regurgitation)
mid diastolic murmurs (mitral stenosis)

Continuous murmurs (Patent Ductus Arteriosus ,BT shunt)

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
Greet
introduce
General Approach

Nutrional status
Work of breath
Color
Dysmorphisim
Monitoring

Growth Parameter
Vital sign
Pulse rate
Respiratory Rate
Blood pressure

Clupping
Capillary refill

Pericordium exam