Cardiovascular examination
1- WIPPPER:
- wash hands
- Introduce yourself
- take permission
- position (lying in 45 degree)
- ensure privacy
- Exposure ( the entire chest till the umbilicus)
- Rt side of the patient
2- ABCDE:
[A]- Appearance+ Alertness: ill or well, is the child engaged and alert or quiet.
[B]- Body built: underweight( CHD or cardiac problem causing HF), overweight, average
[C]- colour and consciousness: pale, jaundice, cyanosed , comatose,conscious, sleeping
[D]- Decubitus>> setting or laying or on mother’s lap
- Deformity>> scoliosis, kyphosis, and kyphoscoliosis
- Distress>> tachypnea, flaring of ala nasi, intercostal+ subcostal+ suprasternal recession,
cyanosis, grunting, head nodding
Down syndrome Turner syndrome - Dysmorphic feature>> look for syndromic features
- Hydration status>> well or dehydrated (dry tongue, sunken eyes, thirst, dry mucous
membrane)
[E]- Environment: connections to patient (monitor, oxygen, IV line)
3- Vital signs:
HR, BP, O2 sat, temp, RR
4- Growth parameters:
you should ask for weight, height, head circumference
5- General examination:
[1]- Hands:
- Clubbing
- osler nodes, Janeway lesion, splinter hge (IE)
- Tendon xanthoma (hyperlipidemia)
- palmar creases pallor
- peripheral cyanosis
- capillary refill
- pulses (rate, rhythm, volume, wall of vessel, synchronicity)
* (brachial pulse in infant and radial pulse in older children)
* assess the rate if it’s regular in 30 sec and multiply it by 2 but ideally you should count it in a full minute
* Rhythm ( regular or irregular)
* volume is subjective either (large, good, or low volume) the objective method is pulse oximetry (wide pulse pressure confirm the collapsing
pulse)
* Synchronicity (feeling the two beats at the same time) check radio radial delay and radio femoral delay
* Peripheral pulsation usually if you feel the radial you will feel other pulses but if you can’t feel it (posterior tibial, dorsalis pedis, and
popliteal)
+ compressible * vessel wall usually in older patients
[2]- arm for BP to measure pulsus paradoxus
[3]- JVP:
* position in 45 degree
+ have an upper limit
* ask the ptn to tilt his head to the left
* try to locate the IJV it’s located between the sternal and clavicular head of the sternocleidomastoid muscle
* if you find it you should measure the distance between the sternal angle and the highest plustile point of IJV
normally between 1-3 and slightly increase with hepatojugular reflex
[4]- Face:
* eyes>> conguctiva for pallor, sclera for jaundice, xanthlesma
* mouth>> dental hygiene, cyanosis, high arched palate, tonsils
6- local examination:
[1]- Inspection:
* Scars>> surgical (midline sternotomy, lateral thoracotomy, axilla, if no visible scars ask about catheter) non surgical scars like (catury marks
and accidental)
* asymmetry like bulging of pericardium due to cardimegaly
* visible pulsation (neck, apex pulsation)
* deformities (pectus excavatum, cranitum, Harrison sulcus)
[2] palpation:
* Apex beat: cardiac impulse lower most outer most position (usually located in 4th intercostal space midclavicular
line) you should comment on the site+ quality (heaving ﺷﻲ ﯾﺧﺑط ﺑﯾدكin volume overload or tapping ﺗﺣس ﺷﻲ ﯾدق ﺑﯾدكin
aortic stenosis and coarctation of aorta), if absent check the Rt side for dextrocaedia
* Thrill (palpable murmur): you should comment on timing( systolic with pulsation or diastolic without the pulsation),
localised or radiated, feel it along the valves by the palm of hand or flat of ur fingers
* Parasternal heave: in the Lt parasternal area by the heel of hand which indicates Rt ventricular hypertrophy
* palpable 2nd heart sound: along the pulmonary area indicates pulmonary HTN
* any other pulsation: you should palpate it
[3]- Auscultation:
* Auscultate the 4 valves, Lt infraclvicular (PDA),Rt side for dextrocardia
* Heart sounds: S1( closure of AV valves best heard at the apex) S2 (closure of semilunar valves best
heard at pulmonary area there is a normal splitting but fixed splitting indicates ASD)
* murmur: along the valves comment on (site of maximum intensity, timing, grade, radiation, duration)
* Additional sounds: S3+ S4 for gallop rhythm, ejection click, pericardial rub, opening snap
7- End ur examination by:
[1]- palpate liver for hepatomegaly seen in Rt side heart
failure and spleenomegaly seen in IE
[2]- Auscultate and percuss the lungs for basal
crepitation seen in HF
[3]- palpate LL and sacrum looking for edema
Murmurs in CHD
--
•
Pansystolic Ejection systolic
Occupied the whole systole located
crescendo decrscendo in LUSB
in LLSB
1at-f.
are
bagIlog at In aortic area In pulmonary Below Lt
VSD aortic stenosis area pulmonary clavicle PDA
AV canal Tricuspid and Truncus and coarctation stenosis or ASD
mitral regurge arteriosus of aorta
References:
https://youtu.be/Mkct2ISsJCE?si=YIl1ZvzIYmYgEjkS
https://youtu.be/Glh5UGQbzY0?si=w4vc8gKd-9zyn288
https://youtu.be/rxZc2Of3ZCM?si=2ailqMV-AduopO62
https://geekymedics.com/paediatric-cardiovascular-examination-osce-guide/
Taif Alsaadi
with cyanosis
