Cardiac
Examination

LEARNING OUTCOME
BY THE END OF THIS LECTURE STUDENTS SHOULD BE ABLE TO:
Demonstrate knowledge to perform a cardiovascular examination in
children.

Introduce yourself to the
patient +/- mother
Ask permission and remove clothing from the upper
part of the body.
Place child at an angle of 45⁰

General Inspection
Observe child from the end of the bed
◦ Dysmorphic features
◦ Nutritional status
◦ Cyanosis
◦ Chest asymmetry
◦ Respiratory distress
◦ Plethoric facies
◦ Obvious scars

Upper limbs - inspection
Inspect hand for
◦ Clubbing
◦ Palmar pallor
◦ Splinter haemorrhages (under the nail bed; also
check toe nails).
◦ Osler nodes( tender swollen 2-15mm)

Upper limbs -palpation
Feel for pulses
◦ Radial
◦ Brachial
◦ Feel both radial and femoral pulses ( absent femoral
pulses with normal/increased brachial pulse suggests
coarctation of aorta.

Upper limbs - palpation
 Assess the pulse for
◦ the presence
◦ Rate
◦ Rhythm
◦ Character or volume or amplitude ( e.g bounding, full,
thready)
• Lift up the arm to check for hyperdynamic pulsation (e.g
aortic regurgitation)
 Measure Blood pressure in both upper limbs

Head and neck
Inspection
◦ Look at conjunctivae for anaemia, jaundice (haemolysis
due to artificial valves)
◦ Look in the mouth:
◦ Tongue – cyanosis
◦ Teeth for dental hygiene – Caries = risk for SBE
◦ Check JVP in order child (at 45⁰)
Palpation
◦ With prior explanation
◦ Check if trachea is central
◦ Feel carotid thrill

Chest -inspection
 Note the Respiratory rate
Scars
Symmetry
Apical pulsation

Chest -palpation
Feel the apex position
◦ Use sternal angle as guide (2nd ICS)
◦ Apex usually on 5th ICS in MCL

Chest - Palpation cont’d
Feel
Thrill in all valvular areas
◦ Mitral –apex
◦ Aortic- 2nd ICS RSB
◦ Tricuspid- 4th ICS LSB
◦ Pulmonary-2nd ICS LSB
heave
◦ Apex (LV), parasternal (left sternal edge -RV), substernal
(RV).
◦ Pulmonary area for P2 (pulmonary hypertension)

Chest - Auscultation
With the stethoscope
◦ Listen in all the valvular areas
◦ Starting with the apex
◦ Feel pulse to time heart sounds and additional
sounds

Chest - Auscultation cont’d
First heart sound (mitral and tricuspid closure) –best heard
at apex/LLSB.
Second heart sound (closure of aortic and pulmonary valves
– ULSB (pulmonary area)
Note for S1 and S2 intensities and whether S2 splits
normally with respiration.
Then, listen for any other sounds
Roll to the left to accentuate mitral murmurs

Chest - Auscultation cont’d
Murmurs
1. Site
2. Radiation
• Axilla (mitral)
• Neck (aortic)
• Back (pulmonary, coarctation)

Chest - Auscultation cont’d
3. Timing
◦ Systolic - between S1 and S2
◦ Ejection systolic murmur – interval between S1 and
murmur.
◦ Regurgitant systolic murmurs – no gap between S1 and
murmur. (MR, TR)
◦ Pansystolic
◦ Continuous
◦ Diastolic – between S2 and S1

Chest - Auscultation cont’d
4. Intensity
◦ 1-6 for systolic
◦ 1-4 for diastolic
5. Character
◦ Eg , harsh(VSD), high pitched or blowing(MR,VSD),
vibratory or humming (innocent )

Chest - Auscultation cont’d
Grading of Intensity
◦ Systolic
◦ Grade 1, barely audible
◦ Grade 2, soft but easily audible
◦ Grade 3, moderately loud but not accompanied by a thrill
◦ Grade 4, louder and associated with a thrill
◦ Grade 5, audible with the stethoscope barely on the chest
◦ Grade 6, audible with the stethoscope off the chest

Chest - Auscultation cont’d
Tilt patient forward
◦ Listen over the back for
◦ Radiation of murmurs
◦ Inspiratory crackles (especially the bases with left
cardiac failure)
◦ Palpate back for sacral oedema (RVF)

Systolic Murmurs at Various Locations
LUSB
◦ Pulmonary valve stenosis
◦ Atrial septal defect
◦ Coarctation of the aorta
◦ PDA
LLSB
◦ VSD
◦ Tricuspid regurgitation
APEX
◦ Mitral regurgitation
RUSB
◦ Aortic Valve stenosis

ABDOMEN
Palpate the abdomen for hepatomegaly ( congestive cardiac
failure)
Pulsatile liver (tricuspid incompetence)
Splenomegaly ( SBE)

Lower Limbs
Inspection
◦ Clubbing
◦ Splinter haemorrhages
Palpation
◦ Test for pitting oedema over the ankles ( (RVF)

Eyes
If SBE likely – Ophalmoscope for Roth spots.