Cardiovascular Examination Guide

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1. On approaching a child:

Around room  Oxygen tank (pulm HT); Saturation monitor

View from Distance

  • Nutritional status: ‘I would like to plot his height and weight on a growth chart’
  • Work of breathing: Respiratory rate, recessions
  • Cyanosis
  • Dysmorphism – top 3 syndromes: Down’s Williams, Digeorge
  • Other possible syndromes related to CVS: Turner’s , Noonan’s

2. Fingers:

  • Clubbing
  • Peripheral cyanosis
  • Splinter haemorrhages
  • Capillary refill


  • Janeway lesion
  • Osler nodes
  • Tuberous and tendon xanthomas of familial hypercholesterolaemia

 Bony abnormalities: Absent Radii (VACTERYL Syndrome)
                               Absent Thumb (Holt-Oram Syndrome)

Pulse- Radial and brachial
HR (Count, rhythm, character) – count over 6 sec X10
Blood pressure
Radio-radial delay
Radio-femoral delay

 Note: if cannot feel pulses – say ‘pulses are difficult to feel’

3. Face

Eyes: Sclera – Jaundice ( Congestive cardiac failure à Hepatic congestion)
Conjunctive – Pallor (Anaemia)

 Face: Mitral flush / malar flush
         Polycythaemia  (Cyanotic heart disease à Increased haematocrit)

Tongue: Central cyanosis ( Right to left shunt/ Inadequate oxygenation in lungs)

Lips/oral mucosa: Pallor

Teeth: Dental Caries

Palate: High arch palate (Marfan’s)

Conjunctival injection and gum hypertrophy = chronic cyanosis

4. Neck:

JVP : Only in older children: Right heart failure, fluid overload)

Suprasternal notch : thrill in aortic stenosis

5. Praecordium


1.       Scars: Back scars (link – pictures)
        Front scars (link)
          See notes in blue for more information on scars

2.       Visible pulsations (hyperdynamic apex beat)

3.       Chest wall deformity
          Anterior bulge chest (cardiomegaly)
          Harrison sulcus (Increased pulmonary blood flow / asthma)

 4.       Respiratory rate


Cardiology scars

Right thoracotomy scar
A. Cardiac causes
1. BT shunt
2 . PA banding
B. Noncardiac causes
1. Thoracotomy
2 . Lobectomy
3. Oesophageal surgery (tracheoesophageal fistula repair)
4 . Congenital diaphragmatic hernia repair ( scar may migrate up)

Midline sternotomy scar
– Complex cardiac surgery
– Any bypass surgery
– PA banding

Left thoracotomy scar
A. Cardiac
1. BTshunt  (  old fashioned – no pulse on ipsilateral side ; new fashioned: pulse present)
2. PA banding
3. PDA ligation
4. Coarctation of aorta repair
B. Non cardiac
1. Thoracotomy
2. Lobectomy

Chest drain scars
Mediastinal drains
Chest wall pacemaker

Messy median sternostomy scars  If no  murmurs:  differential  includes  hypoplastic leftheart syndrome due to Norwood 1 , 2, 3 .

Scars for Tetralogy of Fallot
Left or right thoracotomy scars in association with pulse on corresponding side
If bilateral thoracotomy scars —  failure of one shunt and the need for second shunt procedure
Central sternotomy  scar indicates definitive repair carried out –  Childmay not be cyanosed  , but may still  have right ventricular outflow stenosis

Notes on Cardiac Procedures

1 .  Repair :  VSD ,  ASD , Tetralogy of Fallot repair
2 .  Palliative:
A. Temporary:
BT shunt( to allow for pulmonary blood  flow, encourage deviation ofpulmonary tree )
PA banding (  prevent overloading of thepulmonary circulation pending repair of large VSD )

Atrial septostomy (  transposition of great arteries )


1. Apex Beat (Use both hands to feel both sides)

a)       Site

Displaced to left: Cardiomegaly, pectus excavatum, scoliosis

Displaced to right: Congenital dextrocardia (feel for liver- Kartagener syndrome),
                             Left diaphragmatic hernia,
Collapsed lung on right,
Left pleural effusion,
Left pneumothorax

 b) Character: Sustained
    Forceful (LVH)
Thrusting : Volume overload (Large stroke volume ventricle in mitral/aortic incompetence, or left to right shunt)

2. Left parasternal heave à Right IVH / RV outflow tract obstruction

3. Thrills:               

Thumb palpate at suprasternal notch for thrills at the same time
Lower left sternal edge: VSD
Upper left sternal edge: Pulmonary stenosis


Image source:



Auscultate areas:

1.Mitral area (Apex area) to Tricuspid area (LLSE) to Pulmonary area (LUSE) to 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



Ejection systolic:

   Pulmonary stenosis


   Innocent murmur




Ejection systolic: Aortic stenosis

Continuous: Rt BT shunt

Venous hum



Pansystolic: Mitral regurgitation



Late systolic: Mitral Valve Prolapse

Ejection Systolic: Aortic stenosis

Mid-diastolic: Mitral stenosis



Pansystolic: Tricuspid regurgitation


Diastolic: Tricuspid stenosis

            Aortic regurgitation

Still’s murmur


Systolic: coarctation (between scapulae), peripheral pulmonary stenosis

 Continuous: PDA


5 types of normal murmur:

  1. 1.       Still’s murmur (LLSE)
  2. 2.       Pulmonary flow murmur
  3. 3.       Venous hum
  4. 4.       Supraclavicular/ carotid bruit
  5. 5.       Neonatal physiological peripheral artery stenosis murmur

Innocent murmur do not radiate

Pulmonary stenosis murmur radiate to the back and axilla

Mitral regurgitation radiates to left axilla


To differentiate aortic stenosis from pulmonary stenosis:

Murmurs louds in expiration à Left heart disease à Aortic stenosis

Murmurs loudest in inspiration à Right heart disease  à Pulmonary stenosis


If there is a murmur, describe by:

          Systolic / diastolic murmur


          Loudness   (Grade 1-6)


          Character: harsh, blowing, high-pitched, low-pitched

Anything else?

I would like to complete my cardiovascular examination by:

  1. Feeling for hepatomegaly
  2. Feeling for femoral pulses and looking for scars on inguinal area for cardiac catheterisation/ arterial lines
  3. Measure blood pressure and oxygen saturation  (if not mentioned earlier )
  4. Measure height and weight and plot on growth chart appropriate for age and size
  5. Feeling for peripheral and sacral oedema
  6. Auscultate lung bases (if not done earlier)


Don’t panic. Speak sense

When you present: Rather than describing your entire examination in detail, please present the salient points:

  1. Cyanosis/Pink
  2. Stable/not in respiratory distress
  3. Clubbing
  4. Scars
  5. Heart sounds  I + II +  murmur (grade)

Example of presentation:

I examined Peter, a 7-year-old boy who looks well-grown for his age and I would like to plot his height and weight on a growth chart.
He is pink and not in respiratory distress. There are no dysmorphic features or finger clubbing. There are no scars on his chest. There is a palpable thrill at his suprasternal notch. He has a grade 3/6 ejection systolic murmur at right upper sternal edge radiating to carotid area.
He has left ventricular outflow obstruction such as aortic stenosis.

Author: Dr. Huey Miin Lee, 2013

15 comments on “Cardiovascular Examination Guide
  1. Sabyasachi Chowdhury says:

    Well done. It is a really helpful & probably first of its kind to help out trainees to pass MRCPCH clinical exam. It would be more helpful if you help us with more videos especially communication scenarios & presentation of clinical cases to examiners.
    Thank you.

  2. dr yousif says:

    thanks thanks thanks for this great job…
    thanks again..

  3. Alezzi says:

    Presence of thrills means the murmur is grade 4/6
    Thanks for the above description which is very helpful in the clinical exam

  4. dr adnan says:

    Great job !

  5. obayda says:

    I thank you very much for this very useful and brilliant site materials..

    It is mentioned up that diaphragmatic hernia repair will result in a right thoracotomy scar but isn’t that it results in left thoracotomy scar most commonly?? (right sided are very rare).

  6. hasanul says:

    thanks.very brilliant and very helpful

  7. ayman says:

    Very helpful. ..Thank u alot

  8. Abayneh Aringa says:

    it’s good teaching work,thank you a lot!!!

  9. yasser says:

    Thanks a lot

  10. DR MANOJ JANGID says:

    Very Useful information …Thanks .

    Mnemonic suggestion
    Left heart disease murmurs loud in expiration (AS)…E for E
    Right heart disease murmur loud in inspiration (PS)…I for I

  11. Dr. Yousef says:

    Thank you very much. It seems simple and perfect.

  12. Atraz says:

    thank u very much! It was very informative and helpful. Well done!

  13. Islam says:

    Great effort .. well done …
    I find it so helpful…
    thanx alot ..

  14. jne says:

    i also found a detailed lecture of this at

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