11/13/24, 7\:07 PM Guide | Paediatric cardiovascular exam

Paediatric cardiovascular exam

Table of contents

Background

The paediatric cardiovascular exam can be a logistical mine
possible congenital anomalies. With babies especially, it’s important to be opportunistic with your examination – doing the
three ‘quiet things’
With all children, don’t expect to follow a pre-de
involving parents, siblings and the toys available to you.

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the parents and the child, including your name and role.
Con
Brie
" T o d a y I' d l i k e t o p e r f o r m a n e x a m i n a t i o n o f
y o u r c h i l d' s h e a r t , w h i c h w i l l i n v o l v e
s t e t h o s c o p e .
"
Gain consent from the parents/carers and/or child before proceeding\: " A r e y o u h a p p y f o r m e t o c a r r y o u t t h e e x a m i n a t i o n ?"

General inspection

Appearance and behaviour

Observe the child in their environment (e.g. waiting room, hospital bed) and take note of their appearance and behaviour\:
Activity/alertness\: note if the child appears alert and engaged, or quiet and listless.
Cyanosis\: bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to
hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Shortness of breath\: may indicate underlying cardiovascular (e.g. congenital heart disease) or respiratory disease (e.g.
asthma).
Pallor\: a pale colour of the skin that can suggest underlying anaemia (e.g. blood dyscrasia, chronic disease) or poor
perfusion (e.g. congestive cardiac failure).
Oedema\: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites). There are many causes
of oedema including cardiac failure and nephrotic syndrome.
Rashes\: note the characteristics and distribution of any skin rashes (e.g. petechiae suggesting clotting disorder).
Weight\: note if the child appears a healthy weight for their age and height.
Syndromic features
Pay attention to features that may indicate the presence of an underlying genetic condition\:
Stature (e.g. tall/short)
Syndromic facial features
See the end of this guide for a non-exhaustive list of clinical syndromes which can be associated with cardiovascular system
pathology.
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Equipment

cardiovascular system\:
Observe for any equipment in the child's immediate surroundings and consider why this might be relevant to the
Oxygen\: saturation probe, mask, nasal prongs, oxygen tank and other breathing support.
Mobility equipment\: wheelchair, crutches and walking frame.

Medications

Note any medications by the bedside or in the child's room and consider what underlying diagnoses they may indicate\:
Anticoagulants (e.g. warfarin/heparin)\: commonly prescribed for children with arti
Antihypertensives (e.g. ACE inhibitors)
Diuretics (e.g. furosemide)\: often used in the management of heart failure.
Cyanosis caused by hypoplastic left ventricle [1]

Hands

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.

Inspect the hands

General observations
Inspect the hands for clinical signs relevant to the cardiovascular system\:
Colour\: pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying
hypoxaemia.
Xanthomata\: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow.
Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for
cardiovascular disease (e.g. coronary artery disease, hypertension).
Arachnodactyly (‘spider
and arch of the foot. Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse
and aortic dissection.
Absent thumbs\: associated with Holt-Oram syndrome, an autosomal dominant genetic condition which causes
abnormalities in the bones of the arms and hands as well as the heart (atrial septal defect, heart block).
Finger clubbing
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Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal
angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those
most likely to appear in a cardiovascular OSCE station include congenital cyanotic heart disease and infective endocarditis.
To assess for
Ask the child to copy you in placing the nails of their index
In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window).
When
If the child is too young for this to be possible, you can simply inspect the
terminal phalanx of the digits.
Signs in the hands associated with endocarditis
There are several other signs in the hands that are associated with endocarditis including\:
Splinter haemorrhages\: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include
local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
Janeway lesions\: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and
soles). Janeway lesions are typically associated with infective endocarditis.
Osler’s nodes\: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the
are typically associated with infective endocarditis.
Xanthomata [4]

Palpation

Temperature
Place the dorsal aspect of your hand onto the child's to assess temperature\:
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure, cardiac shunting).
Capillary re
Measuring capillary re
Apply
In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two
seconds.
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A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure)
and the need to assess central capillary re

Pulses

Radial pulse
Palpate the child's radial pulse, located at the radial side of the wrist, with the tips of your index and middle
longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
In babies, assess the femoral pulse instead.
Heart rate
Assessing heart rate\:
You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds
and multiplying by 2 or measuring for 15 seconds and multiplying by 4.
For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.
Radio-radial delay
di
Radio-radial delay describes a loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at
To assess for radio-radial delay\:
Palpate both radial pulses simultaneously.
In healthy individuals, the pulses should occur at the same time.
If the radial pulses are out of sync, this would be described as radio-radial delay.
Causes of radio-radial delay
Causes of radio-radial delay include\:
Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
Aortic coarctation
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Palpate the radial pulse

Jugular venous pressure (JVP)

Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is possible because the internal
jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood. The
presence of this continuous column of blood means that changes in right atrial pressure are re
atrial pressure results in distension of the IJV).
The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid,
making it di
sternocleidomastoid muscle).
Because of the inability to easily visualise the IJV, it's tempting to use the external jugular vein (EJV) as a proxy for assessment
of central venous pressure during clinical assessment. However, because the EJV typically branches at a right angle from the
subclavian vein (unlike the IJV which sits in a straight line above the right atrium) it is a less reliable indicator of central venous
pressure.
See our guide to jugular venous pressure (JVP) for more details.

Measure the JVP

Assessment of the JVP is only performed in children older than 8 years old\:
1. Position the child in a semi-recumbent position (at 45°).
2. Ask the child to turn their head slightly to the left.
3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of
the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the
sternocleidomastoid. The IJV has a double waveform pulsation, which helps to di
carotid artery.
4. Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV
(in healthy individuals, this should be no greater than 3 cm).
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Observe the JVP
Causes of a raised JVP
A raised JVP indicates the presence of venous hypertension. Cardiac causes of a raised JVP include\:
Right-sided heart failure\: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of
right-sided heart failure.
Tricuspid regurgitation\: causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis\: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying
causes.

Face

Observe the child's facial complexion and features, including their eyes, ears, nose, mouth and throat.

General appearance

Inspect the general appearance of the child's face for signs relevant to the cardiovascular system\:
Malar
Nasal

Eyes

Inspect the eyes for signs relevant to the cardiovascular system\:
Conjunctival pallor\: suggestive of underlying anaemia. Gently pull down their lower eyelid to inspect the conjunctiva.
Xanthelasma\: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.
Kayser-Fleischer rings\: dark rings that encircle the iris associated with Wilson's disease. The disease involves abnormal
copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can
cause cardiomyopathy).

Mouth

Inspect the mouth for signs relevant to the cardiovascular system (tip - ask the child to see how long their tongue is or how
big their mouth is)\:
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Central cyanosis\: bluish discolouration of the lips and/or the tongue associated with hypoxaemia (e.g. a right to left cardiac
shunt).
Angular stomatitis\: a common in
including iron de
High arched palate\: a feature of Marfan syndrome which is associated with mitral/aortic valve prolapse and aortic
dissection.
Dental hygiene\: poor dental hygiene is a risk factor for infective endocarditis.
Conjunctival pallor

Close inspection of the chest

Ask the parent or child (if appropriate) to expose the child's chest.
Tip\: If you ask a child to show you their tummy they'll almost always lift their top up to expose their chest as well.

Closely inspect the anterior chest

Look for clinical signs that may provide clues as to the child's past medical/surgical history\:
Scars suggestive of previous thoracic surgery\: see the thoracic scars section below.
Pectus excavatum\: a caved-in or sunken appearance of the chest (e.g. Marfan syndrome).
Pectus carniatum\: protrusion of the sternum and ribs (e.g. Noonan syndrome).
Visible ventricular impulse\: normal in thin children, can be associated with left ventricular hypertrophy.
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Pectus carinatum [12]
Thoracic scars
Median sternotomy scar\: located in the midline of the thorax. This surgical approach is used for cardiac valve
replacement and pulmonary artery banding.
Right thoracotomy scar\: located between the lateral border of the sternum and the mid-axillary line at the 4 th th
or 5
intercostal space on the right. This surgical approach is used to perform pulmonary artery banding and a Blalock–
Taussig shunt.
Left thoracotomy scar\: located between the lateral border of the sternum and the mid-axillary line at the 4 th th
or 5
intercostal space on the left. This surgical approach is used to perform pulmonary artery banding, patent ductus
arteriosus ligation, a Blalock–Taussig shunt and coarctation of the aorta repair.
Infraclavicular scar\: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker
insertion.
Left mid-axillary scar\: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-
de
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Subclavicular incision

Palpation

Start with the abdomen and then work up to the chest. If appropriate, ask the child what they ate for their last meal and try to
‘
. If you can’t ‘
, you’ll have to listen – leading you to auscultation (sneaky right?)

Abdomen

Before beginning abdominal palpation\:
The child should already be positioned lying
Kneel beside the child to carry out palpation and observe their face throughout the examination for signs of discomfort.
Liver palpation
In a healthy child, the liver edge may be palpated up to 2cm below the costal margin. If the liver edge is more prominent, it
would suggest the presence of hepatomegaly. Heart failure is a potential cause of hepatomegaly.
1. Begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the
radial side of your right index
2. Ask the child to take a deep breath and as they begin to do this palpate the abdomen. Feel for a step as the liver edge
passes below your hand during inspiration (a palpable liver edge this low in the abdomen suggests gross hepatomegaly).
3. Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the right costal
margin.
4. As you get close to the costal margin (typically 1-2 cm below it) the liver edge may become palpable in healthy individuals.
If you are able to identify the liver edge, assess the following characteristics\:
Degree of extension below the costal margin\: if greater than 2 cm this suggests hepatomegaly.
Consistency of the liver edge\: a nodular consistency is suggestive of cirrhosis.
Tenderness\: hepatic tenderness may suggest hepatitis or cholecystitis (as you may be palpating the gallbladder).
Pulsatility\: pulsatile hepatomegaly is associated with tricuspid regurgitation.
Splenic palpation
If hepatomegaly is present, you should also assess for splenomegaly. See the paediatric abdominal examination guide for
details on how to perform splenic palpation.
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Palpate the liver

Chest

Palpate the apex beat
Palpate the apex beat with your
Normal position\:
\<7 years old\: 4 th
>7 years old\: 5 th
Abnormal position\:
intercostal space to the left of the midclavicular line.
intercostal space in the midclavicular line.
Left displacement\: causes include cardiomegaly, pectus excavatum and scoliosis.
Right displacement\: causes include dextrocardia, left diaphragmatic hernia, collapsed right lung, left pleural e
left tension pneumothorax.
Assess for heaves and thrills
Heaves\:
A parasternal heave is a precordial impulse that can be palpated.
Place the heel of your hand parallel to the left sternal edge (
Tip\: Instead of the heel of your hand, use your
If heaves are present you should feel the heel of your hand being lifted with each systole.
Parasternal heaves are typically associated with right ventricular hypertrophy.
Thrills\:
A thrill is a palpable vibration caused by turbulent blood
You should assess for a thrill across each of the heart valves in turn (see valve locations below).
To do this place your hand horizontally across the chest wall, with the
assessed.
Valve locations
Mitral valve\: 5th intercostal space in the midclavicular line.
Tricuspid valve\: 4th or 5th intercostal space at the lower left sternal edge.
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Pulmonary valve\: 2nd intercostal space at the left sternal edge.
Aortic valve\: 2nd intercostal space at the right sternal edge.
Palpate the apex beat

Auscultation

Auscultate the heart

Start by showing the child your stethoscope and demonstrate it on your own chest and/or on one of their toys to familiarise
them with this piece of equipment.
Suggest listening to their chest, making sure the stethoscope diaphragm isn't cold prior to it making contact with the child.
Tip\: Play a game to see who can stay quiet the longest – involve the parents!
Areas of the heart to auscultate
Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope\:
Mitral valve\: 5th intercostal space in the midclavicular line.
Tricuspid valve\: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve\: 2nd intercostal space at the left sternal edge.
Aortic valve\: 2nd intercostal space at the right sternal edge.
Repeat auscultation across the four valves with the bell of the stethoscope.
Bell vs diaphragm
The bell of the stethoscope is more e
mid-diastolic murmur of mitral stenosis. The diaphragm of the stethoscope is more e
sounds, including the ejection systolic murmur of aortic stenosis, the early diastolic murmur of aortic regurgitation and
the pansystolic murmur of mitral regurgitation.
Tip\: Complex cardiac anomalies may cause you to hear multiple dynamic murmurs (e.g. Tetralogy of Fallot).
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Heart valve locations

Auscultate the lungs

Auscultate the lung
Ask the child to take ‘big breaths’
- some abnormal sounds may be inaudible if the child is taking shallow breaths.
Auscultate each side of the chest in a symmetrical pattern, comparing side to side.
Pay attention to the inspiratory and expiratory sounds at each placement.
Note the quality and volume of breath sounds and note any additional sounds.
Coarse bibasal crackles may be a late sign of pulmonary congestion secondary to congestive heart failure.
Areas to auscultate the lungs on the anterior chest wall
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Final steps

Assess for evidence of oedema\:
Ask the parents if the child looks pu
Inspect the limbs, sacral area and face\: a
Peripheral oedema often occurs in right-sided heart failure.
Periorbital oedema in nephrotic syndrome [2]

To complete the examination...

Explain to the child and parents that the examination is now
Ensure the child is re-dressed after the examination.
Thank the child and parents for their time.
Explain your
Ask if the parents and child (if appropriate) have any questions.
Dispose of PPE appropriately and wash your hands.
Summarise your

Further assessments and investigations

Suggest further assessments and investigations to the examiner\:
Abdominal examination\: if hepatomegaly was noted.
Respiratory examination\: if abnormalities noted during inspection and auscultation of the chest.
Peripheral vascular examination\: if poor peripheral perfusion or oedema were identi
Vital signs
ECG\: if concerned about cardiac pathology.
Measure and plot height and weight on a growth chart.
Urinalysis\: if oedema present.
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Murmurs

More than 50% of children will have a murmur at some point while congenital heart disease is present in less than 1% of
children. The table below includes a non-exhaustive list of murmur characteristics and underlying causes.
Syndrome Clinical features
Aortic area\: aortic stenosis
Pulmonary area\:
Ejection systolic with
Ejection systolic without
on inspiration)
Subclavian, holosystolic\: patent ductus arteriosus
LOCATION
Lower right sternal edge\: tricuspid regurgitation
Tricuspid area\:
Pansystolic murmur - ventricular septal defect
Diastolic - tricuspid stenosis, aortic regurgitation
TIMING
Apex\: mitral regurgitation - increases on lying on left, radiates to the axilla
Systolic
Diastolic
Continuous
DURATION
Mid-systolic (ejection)
Pan-systolic
LOUDNESS (systolic murmur
grade)
SITE OF MAXIMAL INTENSITY
1-2\: Soft, di
3\: Easily audible, no thrill
4-6\: Loud, with a thrill
Mitral
Pulmonary
Aortic
Tricuspid area
RADIATION
To the neck\: aortic stenosis
To the back\: coarctation of the aorta or pulmonary stenosis
To the axilla\: mitral regurgitation (increases lying on the left)

Relevant syndromes

Below is a table containing a non-exhaustive list of syndromes that can impact the cardiovascular system.
The features of each syndrome relevant to the cardiovascular system are shown in bold.
Syndrome Clinical features
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Alagille syndrome
In 90 percent of cases, caused by mutations in the JAG1 gene.
CHARGE syndrome
CHARGE syndrome is a genetic syndrome with a characteristic set of features.
DiGeorge syndrome
A constellation of signs and symptoms associated with defective development of the
pharyngeal pouch system. Most cases are caused by a heterozygous chromosomal deletion at
22q11.2.
Down's syndrome
A genetic disorder caused by the presence of all or part of a third copy of chromosome 21.
Broad forehead
Small chin
Flat face
Pulmonary stenosis
Tetralogy of Fallot
Coloboma (of the eye)
Choanal atresia
Heart anomalies (see
below)
Tetralogy of Fallot
Patent ductus
arteriosus
Ventricular septal
defect
Atrial septal defect
Atrioventricular septal
defect
Hearing loss
Cleft palate
Micrognathia
Hypoplastic malar
Ventricular septal
defect
Tetralogy of Fallot
Interrupted aortic arch
Epicanthic folds
Brush
Protruding tongue
Low set ears
Ventricular septal
defect
Atrial septal defect
Atrioventricular septal
defect
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Fetal alcohol spectrum disorder
A range of e
Fragile X syndrome
An X-linked disorder and the most common inherited cause of intellectual disability\: Both
males and females can be a
Marfan syndrome
An autosomal dominant connective tissue disorder.
Noonan syndrome
An autosomal dominant condition. 50% of children have a pathogenic variant in protein tyrosine
phosphatase, nonreceptor type 11 (PTPN11).
Turner syndrome
Caused by loss of part or all of an X chromosome – a
Source\: geekymedics.com
Microcephaly
Intrauterine growth
restriction
Smooth philtrum
Joint abnormality
Ventricular septal
defect
Atrial septal defect
Macrocephaly
Prominent ears and jaw
Hypermobility
Macroorchidism
Mitral valve
prolapse
Marfanoid habitus (tall,
long limbs)
Hypermobility
Arachnodactyly
Chest wall deformities
Aortic
dilatation/regurgitatio
n
Mitral prolapse
Turner phenotype
Pulmonary stenosis
Hypertrophic
cardiomyopathy
Short stature
Delayed puberty
Webbed neck
Shield chest
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