Cardiovascular Examination Guide

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

Hands:

• 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

Inspection:

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)
–          Asymmetry

 4.       Respiratory rate

Scars:

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 )

Palpation

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: http://www.childrenshospital.org/health-topics/procedures/heart-transplant
                      http://en.wikipedia.org/wiki/Hand

Auscultation:

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

If there is a murmur, describe by:

–          Systolic / diastolic murmur

–          Site

–          Loudness   (Grade 1-6)

–          Radiation

–          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)

Conclusions:

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