This document provides information on performing a pediatric cardiovascular examination, including: 1) It outlines the history and signs/symptoms to ask about depending on the age of the child, from newborns to adolescents. 2) It describes the components of the physical examination including inspection, palpation, percussion and auscultation of vital signs, heart sounds, and murmurs. 3) Details are given on using a stethoscope and sphygmomanometer to properly listen to the heart and measure blood pressure at different locations on the body.

1. Paediatric Cardiovascular
System Examination
B H A D R A T R I V E D I , M D P E D I A T R I C S
P E D I A T R I C C A R D I O L O G I S T
R O O M – 5 , B & M P A T E L C A R D I O L O G Y C E N T R E
B H A D R A Y T @ C H A R U T A R H E A L T H . O R G

2. History - Signs and Symptoms S/O CVS involvements
•Newborns and Infants
• Fast breathing
• Difficult breathing
• Grunting
• Poor feeding – poor weight gain
• Sweating – Suck – Rest – Suck – cycle
• Reduced activities
• Cyanosis – Central
•Toddlers and Preschool
• Previous + followings
• Poor breathing and / or feeding
• Limited activities on playground
• Frequent illnesses – cough, cold , fever
• Poor growth
•Older Children and Adolescents
• All previous + extra
• Chest pain
• Syncope
• Dizziness
• Paroxysmal nocturnal dyspnea

3. Relative Information from History
•H/O frequent cough, cold and/or fever
•H/O Hospital admission H/O Surgery
•Perinatal History – Maternal Infection, Maternal autoimmune diseases, Maternal medications
•Family History – ho similar illness
•Syndrome – Phenotype vs Genotype

4. PHYSICAL
EXAMINATION
Aims
 Carry out complete systemic
examinations including all
components
 Child most comfortable in
mother’s lap or while playing
around in OPD area. Child may
be at sleep while brought to
OPD
 Change the sequence based
on the child’s comfort
 Sequence
 Inspection of child
 Auscultation
 Palpation
 Percussion – rarely in pediatrics
 Systems
 CVS
 RS
 Abdominal System - Organomegaly
Components
(1) Inspection – Head to Toe
(2) Palpation – Relevant system first
(3) Percussion
(4) Auscultation

5. Stethoscope Sphygmomanometer
•Bell
• For low-pitched sounds
• Mid-diastolic murmur of mitral stenosis or S3 in
heart failure
•Diaphragm
• Filters out low-pitched sounds
• For high-pitched sounds
• Second heart sound,
ejection and
midsystolic clicks
• Diastolic murmur of
aortic regurgitation 2/3
limb

6. Stethoscope Sphygmomanometer
•Done best when child is un-aware of
examination
•Preferably smaller chest piece for better
localisation
•Areas of interest – four valve area and Lt
Sternal Border
Site of measurement – both upper limb and
one lower limb – Brachial and popliteal
Ideal – both – systolic and diastolic
Systolic blood pressure – Palpation and Flush
technique

7. Vital Signs – high Fives
•Temperature
• Thermometer – accurate. No alternative
• Dorsal aspect of fingers to be used – check for difference between proximal and distal limb
•Heart Rate / Pulse Rate – regularity, volume, radio-radial or radio-femoral delay
•Respiratory Rate – observe for whole one minute, notice use of accessory muscles / flaring nose
•Blood pressure – both upper limbs and one lower limb
•Pulse Oximetry – for cyanosis – Acro-cyanosis

8. Why so many pulses and blood pressures?
1
2
1 – Radio-radial delay
2 – Radio-Femoral delay

9. Cyanosis
Greek word for blue
It is defined as the bluish discoloration of the
skin and the mucous membranes, resulting
from an increase in the reduced Haemoglobin
or of haemoglobin derivatives in the small
vessels of those areas.
Absolute level of reduced hemoglobin in the
capillary bed exceeds 5 g/dL
Depends upon the total amount of reduced
hemoglobin rather than the ratio of reduced
to oxygenated hemoglobin.
The arterial oxygen saturation level at which cyanosis is detectable at different
total hemoglobin concentrations is illustrated above. The solid red portion of
each bar represents 3 gm/dL reduced hemoglobin.

10. Cardiovascular Examination - Inspection
General Appearance – Comfortable / irritable / drowsy / under-sedation
Pallor / Cyanosis / Clubbing / Icterus
Breathing pattern – cyanosis – Non-labored tachypnea / tachypnea with distress / grunting
Scar over the precordium
Precordial Bulging – visible apex impulse
From the feet end of the examination table

11. Cardiovascular Examination - Palpation
•“Confirm inspector findings on Palpation”
•Palpation of Chest, Abdomen and Back – routine in CVS cases
•Pulses – Peripheral Palpation
• Regularity, volume, temperature
• Delay between limbs – coarctation of aorta, cardiac surgery
• Assessment of perfusion – state of shock
•Central Palpation – Chest Wall
• Position of apex beat – “Point of maximal impulse, precordial activity and thrills” – most common – Lt
Mid Clavicular Line – 4th ICS / On Right in Dextrocardia
• RV hypertrophy – Apex at Xiphoid, ill-defined
• Hyperactive – Volume overload | Strong with thrills – Pressure overload
• Thrills – related to shunt lesions and due to valvar stenosis

12. Cardiovascular Examination - Palpation

13. Cardiovascular Examination -
Auscultation
•Heart Sounds
•Murmurs
•Friction Rubs
•Clicks
•Respiratory Auscultation
Grades of Murmur

14. Diastole
◦ TV & MV – open
◦ Pressure - RA = RV | LA = LV
Systole
◦ AV & PV – open
◦ Pressure - LVs = Ao(s) | RVs = PA(s)
Normal Cardiac Circulation

15. Normal Cardiac
Cycle

17. Heart Sounds
FIRST HEART SOUND – S1 (M1T1) SECOND HEART SOUND (A2P2)

18. Heart Sounds – Third and Forth
THIRD SOUNDS
Early diastole with rapid filling of ventricles
Low frequency
Heard best with bell @ Apex
Gallop – Third sound + tachycardia = failure
FOURTH HEART SOUNDS
Pathological
S/O – cardiac failure
Filling of ventricles in late diastole due to atrial
contractions

19. Heart Murmur
Abnormal sounds
Caused by vibration and turbulences

20. Heart Murmurs
Systolic Murmurs
A. Ejection systolic murmur
B. Pansystolic murmur
C. Late systolic murmur

21. Heart Murmur
Diastolic Murmurs
A. Early Diastolic Murmurs
B. Mid-Diastolic Murmurs
C. Late Diastolic Murmurs

22. Heart Murmur
Continuous Murmur
Vs
To and Fro Murmur

23. Tale of Two
Murmurs
( Diastolic)
Graham Steel Murmur
Graham Steel Murmur
Austin Flint Murmur
Austin Flint Murmur