CVS

Skill lab
inspection
• General health – nutritional status, failure to thrive, tachypnoeic
• Dysmorphic features- Down’s, Turner’s
Face
• Colour
- Cyanosis – desaturated blood in the capillaries > 5 g/dL giving skin
and mucous membranes a bluish discolouration- characteristic of Rt to
Lt shunt
- Central- tongue
- Peripheral- nailbeds
pallor
• Best detected in oral mucosae, lips and conjunctivae. Usually
associated with poor cardiac output, pulses may be weak and tissue
perfusion poor.
polycythaemia
• Often found in cyanotic congenital heart disease.
• High haematocrit and increased viscosity- increased risk of
cerebrovascular events.
Teeth
• Dental caries – importance of dental care
Hands
• Clubbing- increased longitudinal and lateral curvature of nails
• Loss of angle between proximal part of the nail and the skin
Features of IE
• Splinter haemorrhages and Osler nodes, Jamesway lesion
• Respiratory rate
• Scars – thoracotomy scar, midline sternotomy scar
• Pulses- brachial , radial
• Rate –bradycardia, tachycardia
• Rhythm- regular or irregular
• Volume- small, large
• Character – normal, collapsing
• Equality
• Radio femoral delay
• Normal resting pulse rate in children Age Beats/min
• < 1 year 110-160
• 1-5 years 95-140
• 6-12 years 80-120
• > 12 years 60-100
• Rhythm – sinus arrhythmia (variation of pulse rate with respiration) is
normal
• Volume – small in circulatory insufficiency or aortic stenosis;
increased in high-output states (stress, anemia)
• Character: collapsing in patent ductus arteriosus, aortic regurgitation,
and slow rising in ventricular outflow tract obstruction.
• Blood pressure check at end of examination
• Precordium examination- apex beat – displaced or normal
• Any thrill
• Palpation
• Thrill is a palpable murmur (Check over the four valve areas and
suprasternal notch).
• Apex beat: (4th – 5th intercostal space, mid-clavicular line): Not
palpable in some normal infants, plump children and dextrocardia.
Place your hand over the chest with the fingertips in the anterior
axillary line.
• The maximum lateral impulse is found with one fingertip. Define its
position by counting down the ribs starting at the sternal angle which
corresponds to the second intercostal space.
• A forceful apex or displacement of the apex to the left suggests left
ventricular hypertrophy or lung disease distorting the mediastinum.
Parasternal heave: Place your palm over the lower half of the sternum,
a heaving sensation indicates right ventricular hypertrophy. Liver:
hepatomegaly suggests heart failure.
• Ankle edema: peripheral edema and raised JVP are rare in children.
• Capillary refill: poor skin perfusion is a sign of shock.
Percussion
• Cardiac border percussion is rarely helpful in children.
JVP
• 45 degree
• Use Rt internal jugular vein
• Till to left
• Measure between sternal angle and tip of JVP
• Normally less than 4 cm.
Characteristics of JVP
• Not palpable
• Obliterated by pressure
• Double wave pattern
• Reduce in inspiration
• Increase by hepatojugular reflex
Causes of increase JVP
• Heart failure
• Constrictive pericarditis
• Cardiac tamponade
• Fluid overload
• SVC obstruction
Auscultation
• Heart sounds
• Added sounds
• murmur
Normal Heart sound
• First sound- sudden cessation of mitral and tricuspid flow due to valve
closure
• Second sound- sudden cessation of aortic and pulmonary flow due to
valve closure
Loud first sound
• ASD
• Mechanical prosthetic valve
• Mitral stenosis
Loud second sound
• Increased pulmonary blood flow- PDA, ASD, large VSD
• Pulmonary hypertension
Added sound
• Third sound – after second heart sound, early diastole, low pitched (
can be normal in healthy children)
• Best heard with bell over the apex
• Heard in failure of either ventricle.
• Fourth heart sound- never a normal finding.
• It precedes first sound. Can be associated with failure of either
ventricle or pulmonary hypertension.
murmurs
• Intensity
• Site
• Radiation
• Timing ( systolic or diastolic)
• Duration – early diastolic or pansystolic
• Pitch and quality – high or low, harsh or blow
• Changes with respiration or posture
• Remember to listen over the back ( PDA, PS, COA)
• Murmurs Timing – systolic / diastolic / continuous
• Duration – mid-systolic (ejection) / pansystolic
• Loudness – does not correlate with severity.
• Systolic murmurs graded:
• 1 Difficult to hear
• 2 Soft and variable in nature.
• 3 Easily heard, no thrill
• 4 Loud with thrill
• 5 Very loud
• 6 Heard without a stethoscope
Characteristic of innocent murmur
• Usually systolic
• Change with position
• Associated with high fever or metabolic
• Never radiated
Why innocent murmur is commonly heard in
children ?
• Children have thin chest wall.
• More angulated great vessels in children
• More dynamic circulation in children
Anything else
• Feel for hepatomegaly
• Femoral pulses
• Blood pressure
• High and weight
• THANK YOU