This document provides guidance on performing a cardiovascular assessment. It outlines steps to take before the assessment, including washing hands, ensuring privacy, and obtaining consent. It then describes conducting a history, physical exam, making diagnoses, and ordering investigations. The history section delves into various topics like presenting complaints, past medical history, family history, and more. The physical exam section details assessing vital signs, appearance, hands, neck, chest auscultation, and other exam maneuvers.

1. CARDIOVASCULAR
ASSESSMENT
OCTOBER 2021

2. BEFORE THE ASSESSMENT..
Wash your hands!!!
Ensure as much privacy as possible
Introduce yourself to the patient’s guardians and
all patients over 2 years old
Explain what is about to happen i.e. you will be
asking questions about the child’s health and
history and later perform an examination
Get consent before proceeding

3. THE ASSESSMENT
History taking
Physical examination
Provisional diagnosis
Differential diagnosis
Investigations

4. HISTORY TAKING
DEMOGRAPHICS
PRESENTING COMPLAINT
HISTORY OF PRESENTING COMPLAINT
REVIEW OF SYSTEMS
PAST MEDICAL OR SURGICAL HISTORY

5. HISTORY TAKING
DRUG/ALLERGIES HISTORY
BIRTH HISTORY
NEONATAL HISTORY
DEVELOPMENTAL HISTORY
IMMUNISATION HISTORY

6. HISTORY TAKING
NUTRITIONAL HISTORY
FAMILY HISTORY
SOCIAL HISTORY

7. DEMOGRAPHICS
Name of patient
Age of patient
Sex of patient
Address
Informant - adolescents should be encouraged to
provide their own history
Religion

8. PRESENTING COMPLAINTS
Cardiovascular symptom s??

9. PRESENTING COMPLAINTS
Cardiovascular symptoms;
1. Cough – productive vs non-productive
2. Shortness of breath or difficulty breathing
(dyspnea) – at rest? On exertion?
3. Orthopnea – difficulty breathing when lying flat
4. Paroxysmal nocturnal dyspnea (PND) – waking
up from sleep to catch a breath
5. Cyanosis – bluish discoloration of the skin

10. PRESENTING COMPLAINTS
Cardiovascular symptoms;
1. Edema – pedal/sacral/generalized; isolated facial edema
unlikely cardiac, rule out renal or allergic reactions
2. Chest pain – SOCRATES rule
3. Palpitations – mothers may report feeling the child’s heart
beating quickly
4. Intermittent claudication – muscle pain usually in calves
worse on exertion, better with rest ddx PVD
5. Syncope
6. Dizziness

11. HISTORY OF PRESENTING COMPLAINT
How long has the patient been unwell? Acute
vs chronic?
What was the patients previous state of
health? i.e.. Was healthy then became ill or has
been chronically ill then got worse

12. HISTORY OF PRESENTING COMPLAINT
Obtain more detail on presenting complaint;
SOB – rest? Exertion? Orthopnea? PND? breastfeeding with
diaphoresis? (infants in CCF), squatting? (TOF)
Edema – generalized? Location? Unilateral vs bilateral pedal
edema?
Cyanosis – at rest? When crying? Breastfeeding? From birth?
Central? Peripheral?
Chest pain – SOCRATES
Cough – productive/non productive, sputum details??
Dizziness – postural or exertional, associated syncope?

13. CHEST PAIN - DDx
Angina – substernal, crushing, radiates down the left arm or
to the jaw, associated with vomiting, diaphoresis
Aortic dissection – severe central or epigastric pain radiating
to the back, feels like tearing
Pleuritic pain with SOB i.e. lateral chest pain worse with
breathing – pneumonia, pneumothorax, pulmonary
embolism, ACS in SCD
Exertional pain – MI, cardiomyopathy
Pericarditis – sharp retrosternal pain, worse when lying
down, radiates to the left shoulder and associated with fever

14. HISTORY OF PRESENTING COMPLAINT
Associated symptoms :
Patients presenting with only edema and SOB should
be evaluated for
1. Renal disease i.e. urine frequency, color and quantity
2. Malnutrition – feeding habits
3. Allergic reactions; history of insect bites, food
ingestion, drug use prior to onset of edema
4. Liver disease – yellowing of eyes/skin? Itchy skin?
Pale stools? Easy bruising/bleeding?

15. HISTORY OF PRESENTING COMPLAINT
Associated symptoms :
Systemic symptoms e.g.
1. Fever – with chest pain in pericarditis or
endocarditis
2. Easy fatiguability - CCF
3. Weight gain – CCF
4. Poor appetite – CCF in infants

16. REVIEW OF SYSTEMS
*Systemic – fever, fatigue, weight changes
*Respiratory – most overlap with CVS e.g. cough,
SOB, noisy breathing, chest pain
Gastrointestinal –dyspepsia. Nausea, vomiting,
dysphagia, abdominal pain (GERD vs ANGINA/CAD)
Genitourinary – oliguria, polyuria, hematuria (CCF
vs renal failure/nephrotic syndrome), hematuria in
infective endocarditis??

17. REVIEW OF SYSTEMS
Neurological – visual changes, headaches
(syncope –neuro vs cardiac cause)
Musculoskeletal – chest pain, trauma
history?? Joint pain? (rheumatic fever)
Dermatological – rashes? Ulcers? (Rheumatic
fever, vasculitidies e.g. Kawasaki disease)

18. PAST MEDICAL/SURGICAL HISTORY
First presentation or has had similar
symptoms before?
First admission or known patient? Records
available?
Other hospital admissions?
Frequent clinic visits?
History of heart disease?

19. PAST MEDICAL/SURGICAL HISTORY
HIV? TB? –increased risk for pericarditis
Asthma? Wheezing due to cardiac asthma?
Epilepsy? Syncope vs atonic seizure??
Hypertension – renal disease, thyroid
disease(palpitations too) COA
Sickle cell disease – DCM, CCF from severe
anaemia
Previous cardiac surgeries

20. DRUG HISTORY
Prescribed vs OTC?
Use of herbal medications?
Important drugs to note;
1. Beta blockers- propranolol/atenolol (HTN,
hyperthyroidism)
2. Calcium channel blockers e.g. nifedipine (HTN)
3. ACE inhibitors e.g. enalapril in HTN, CCF
4. Diuretics e.g. furosemide, spirono,actone (CCF)
Food and drug allergies – esp for patients with edema

21. ANTENATAL HISTORY
Maternal drug use e.g. lithium for mood
disorders (Epstein anomaly), sodium valproate
for epilepsy (TOF, septal defects), alcohol (FAS)
Maternal illnesses – rubella (PDA), diabetes
mellitus (VSD, AVSD, TGA), SLE, coxsackie
Maternal age at conception – Downs
syndrome (AVSD, endocardial cushion defects)

22. BIRTH HISTORY/NEONATAL HISTORY
Term or preterm delivery – PDA >>> preterm
births
Cyanosis at birth/neonatal period
Shortness of breath in the neonatal period
Difficulties breast feeding, diaphoresis when
feeding
Failure to thrive – child not gaining weight despite
adequate breast feeding

23. DEVELOPMENTAL HISTORY
Failure to thrive – most children with congenital
heart disease have FTT due to either difficulties
with feeding resulting in low energy intake or high
energy requirements
CHD associated with genetic disorders like Downs
syndrome or Edward syndrome may present with
developmental delay i.e. motor, cognitive or
language delays

24. NUTRITIONAL HISTORY
Establish the cause of FTT or possible
malnutrition as a cause for edema
Exclusive breastfeeding? Age of weaning?
Duration of breast feeding? Other foods part of
the diet?
Difficulty breast feeding? Poor appetite?

25. FAMILY HISTORY/SOCIAL HISTORY
Other family members with cardiac disease
E.g. Marfan’s syndrome
History of sudden deaths in the family –
suggestive of arrhythmias e.g. long QT syndrome
Education level of patient
Socio-economic status of parents

26. PHYSICAL EXAMINATION
Vital signs
Arthropometric measurements
LOOK before you TOUCH!!! – inspection,
percussion, palpation, auscultation
Hands  face  neck  chest - abdomen
 extremities

27. VITAL SIGNS
Temperature – fever ?? Think endocarditis,
pericarditis, rheumatic fever, hypothermic??
Assess for shock
Pulse rate/heart rate
Blood pressure – hypotensive (shock?? CCF??)
hypertensive (COA, renal artery stenosis)
Respiratory rate – tachypnea in CCF

28. ANTHROPOMETRIC MEASUREMENTS
Weight – compare with previous weights, FTT??
Weight gain from edema?? SAM??
Height – stunted?? Likely chronic disease e,g,
sickle cell or congenital heart disease
Weight for height
MUAC
Head circumference – microcephalic in torches
like rubella, think PDA??

29. LOOK!!!
Did the patient walk in unaided or were they carried?
Alert or lethargic??
Is the patient sitting up in bed? Unable to lie flat?
Using multiple pillows?
In respiratory distress? Signs of respiratory distress??
On oxygen? Cyanosed?
Edematous?
Pallor? Remember : Severe anaemia causes CCF

30. HANDS
Peripheral cyanosis – cyanotic CHD, Eisenmenger syndrome
Finger clubbing – cyanotic CHD, infective endocarditis
Stigmata of infective endocarditis i.e. Janeway lesions,
Osler’s nodes, splinter hemorrhages
Palmar pallor
Warm or cool peripheries – febrile vs shock
Capillary refill time – peripheral vascular disease vs shock
Arachnodactyly – abnormally long and slender fingers in
Marfan syndrome – risk for MVP or aortic dissection

31. PERIPHERAL CYANOSIS

32. FINGER CLUBBING

33. GRADING FINGER CLUBBING
Grade 1 – nail bed fluctuation
Grade 2 – loss of the Lovibond angle with
obliteration of Schamroths window
Grade 3 – increased convexity of the nail fold with
evident clubbing
Grade 4 – drumstick appearance
Grade 5 – hypertrophic osteoarthropathy (shiny
nail with striae)

34. JANEWAY LESIONS/OSLER’S NODES

35. SPLINTER HEMORRHAGES

36. RADIAL PULSE (wrist)
Rate – tachycardic vs bradycardic, pulse deficit
(>10mmHg A-fib??)
Rhythm – regular, irregular? Irregular irregular?
(atrial fibrillation)
Volume – absent, weak/thready, strong, bounding
Character – collapsing pulse( water hammer) in
aortic regurgitation,
Radial-radial synchrony - RR-delay in COA

37. BLOOD PRESSURE
Standing, sitting, lying down??
Hypotension – CCF, shock
Hypertension – COA, renal artery stenosis, thyroid disease
Narrow pulse pressure (<25 mmHg) – aortic stenosis, CCF,
cardiac tamponade
Wide pulse pressure (>100 mmHg) – aortic regurgitation,
aortic dissection
Difference in right and left arm BP -> 20 mmHg ??arotic
dissection

38. FACE/NECK
Eyes – Roth spots in infective endocarditis,
conjunctival pallor, Kayser Fleischer rings
(Wilsons disease causes cardiomyopathy)
Central cyanosis
High arched palate – Marfan syndrome
Dental hygiene – high risk for infective
endocarditis

39. FACE/NECK
Distended neck veins with increased jugular
venous pressure in CCF, tricuspid regurgitation
or constrictive pericarditis (normal 3-4 cm
above sternal angle)
Carotid pulse – dancing carotid (Corrigan’s
sign) in aortic regurgitation, carotid bruit
(carotid stenosi or radiating murmur from aortic
stenosis)

40. CENTRAL CYANOSIS

41. JVP ASSESSMENT

42. CHEST EXAMINATION
INSPECTION
1. Tachypnea,
2. Chest asymmetry – pectus
excavatum/carinatum,
3. Hyperactive precordium
4. Surgical scars

43. CHEST EXAMINATION
PALPATION
1. Apex beat (point of maximal impulse) – normal
is 4th to 5th intercostal space midclavicular line
(displaced in DCM laterally or downwards)
2. Thrill – palpable murmur in valve disease
3. Parasternal Heave – palpable precordial impulse
in RVH

44. CHEST EXAMINATION
Auscultation
1. Heart sounds
First heart sound (S1) – closure of the atrioventricular valves i.e.
mitral and tricuspid
Second heart sound (S2) – closure of the semilunar valves i.e.
aortic and pulmonic valves
Third heart sound (S3) – AKA ventricular gallop due to passive
filling of the left ventricle in CCF
Fourth heart sound (S4) – AKA atrial gallop produced during atrial
systole by the flow of blood into a poorly compliant ventricle

45. AUSCULTATION

46. CHEST EXAMINATION
Auscultation
Murmurs – sound made by turbulent blood flow in the heart.
Characteristics include;
1. Location
2. Radiation
3. Timing
4. Intensity or grading
5. Frequency (pitch)
6. Shape
7. Quality

47. MURMURS
Aortic stenosis – ejection systolic murmur best
heard in the carotid arteries when the patient holds
their breath
Aortic regurgitation – diastolic murmur best
heard over the aortic area during expiration when
the patient sits forward (RHD)
Mitral regurgitation – pansystolic murmur best
heard over the mitral area or apex beat and radiates
to the axilla (RHD)

48. MURMURS
Mitral stenosis – mid-diastolic murmur obest
heard in the mitral area during expiration with
the patient in left lateral with the BELL of the
stethoscope
Tricuspid regurgitation – pansystolic murmur
in the lower left sternal border
Tricuspid stenosis – mid-diastolic murmur on
the lower left sternal border

49. MURMURS
Pulmonic stenosis – ejection systolic murmur
in the upper left sternal border (TOF, congenital
rubella)
Pulmonary regurgitation – early diastolic
descrescendo murmur in the left upper sternal
border

50. GRADING OF MURMURS
Grade 1 – faint murmur, only heard by experts
Grade 2 – soft murmur, heard in all positions with NO THRILL
Grade 3 – moderately loud murmur, NO THRILL
Grade 4 – loud murmur with a palpable thrill
Grade 5 – very loud murmur with thrill, can be heard with
the stethoscope partly off the chest
Grade 6 – very loud murmur with a thrill, heard with
stethoscope completely off the chest

51. CHEST EXAMINATION
Auscultation
1. Pericardial friction rub – grating or scratching
sound produced by friction of the heart
against the pericardium in pericarditis
2. Basal crepitations – pulmonary edema in CCF

52. ABDOMINAL EXAM
Inspection – distended abdomen with ascites
in CCF
Palpation – fluid thrill, shifting dullness, tender
hepatomegaly in CCF
Hepatojugular reflux in CCF

53. EXTREMITIES
Inspection – edema, peda? Ankle? Sacral?
Generalized?
Palpation of peripheral pulses – dorsalis pedis,
anterior tibialis, popliteal, femoral, carotid,
brachial and radial – absent pulses in PVD
Radial-femoral delay in coarctation of the
aorta