Examination of the CVS
Dr. Kay Bailey
July 2019
Acknowledgements: Dr. Berry, Dr. C. Scott
Examination sequence
• Inspection
• Palpation
• Percussion
• Auscultation
Inspection
APPEARANCE
– Unhappy, irritable, distressed infant, cyanosed
• common finding with serious CHD associated
with CCF
• ( May see Oxygen, IV, Monitor)
– Respiratory distress (RR, Recessions)
• rest and with activity
– Failure to thrive/Nutritional Status
Inspection
– Dysmorphic features
• 5% CHD associated with chromosomal abnormalities
• Many non-chromosomal dysmorphic syndromes
associated with CHD
– Asymmetric bulging chest
• Precordial bulge
– not in first month usually by third month
– Scars
– Hepatomegaly, splenomegaly may cause abdominal
distension
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 4th or 5th 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 4th or 5th 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-defibrillator (ICD).
Scars
• The posterolateral thoracotomy is still probably
the most commonly used incision in general
thoracic surgery. It provides not only excellent
access to the lung, hilum, middle and posterior
mediastinum, endo- thoracic trachea, and
endothoracic esophagus, but it also allows for the
safe control of pulmonary blood vessels during
pulmonary resection. Posterolateral tho-
racotomy offers more accessibility to all areas of
the hemithorax than any other incision.
•
Palpation
• Exam Hands
• Clubbing
• Capillary and digital pulsation
• Cyanosis/Pallor/Redness(Polycythemia)
• SBE signs- Oslers nodes/ Jane way lesions/
splinter haemorrhages
Stages of Clubbing
1. Nail bed fluctuation
2. Loss of angle
3. Increase convexity of the nail
4. Thickened distal phalanx (Drum stick
appearance)
5. Hypertrophic Osteoarthropathy
Palpation
• Pulses
– Assess the brachial /radial pulses for character
and regularity
• Assess for collapsing pulse, rhythm, volume,
rate
• Examine femoral pulses
• Assess for radio-radial delay and radio-
femoral delay (both femorals)
• Ask for Blood pressure
Collapsing pulse
Palpation
• Head/Face
– Skull-Bruit- Newborn AV malformations, CCF
(auscultation)
– Eyes – pallor/polycythemi
– Mouth - central cyanosis, dental caries
• Neck- JVP/ palpate for trachea
– The jugular venous pressure (JVP) is generally not
an important part of the paediatric cardiovascular
system.
Palpation
• JVP can only be measured in older children
– Bed at 45 degrees using a pillow
– Elevated in right heart failure, fluid overload and
pericardial tamponade
• Trachea
• Precordium Palpation
– Apex beat - describe location and character ( both hands
to detect dextrocardia)
– Thrills - describe location, systolic diastolic (Grade 4)
– Parasternal Heave – location
– Palpable sounds - location
• Epigastric pulsation (RVH)
Jugular Venous Pressure
Normal mean atrial pressure is < 9cm
Angle of Louis 5 cm above atrium, so normal JVP no more
than 4 cm above sternal angle
At 45 degrees top of jugular pulse at level of clavicle
Pressing on the abdomen will increase pressure 1-3 cm
Palpation of the Precordium
• Pre-warmed hands GENTLY on the chest both sides
• Apical Impulse
– depress the apical area with tips of right 1st and 2nd fingers
palpating the left and right ventricles as they eject blood
– Normal – concentrated pulsating area to the left of the
sternum at the 4th and 5th space
– Abnormal
• Volume loaded - diffuse and abrupt
• Pressure loaded - forceful and sustained
• Right sided — Dextrocardia
Palpation of the Precordium
• Pulmonary artery pulsation
– Use first and second digit right hand to palpate 2nd interspace at the
left sternal border
– An impulse suggests dilated PA from increased flow or pressure
• Parasternal Heave
– ulnar border right hand left sternum
– RVH
• Epigastric Pulsation
– use tips of right 1st and 2nd fingers to depress the thorax just left of
the xiphoid process.
– A faint Impulse is acceptable.
– Definite forceful movement = RVH
Palpation of the Precordium
• Suprasternal notch
– Place 2nd and 4th fingers right hand on the head of the
clavicles; insert 3rd finger as deeply as possible to asses tracheal
position
– Palpate for thrill if present — AS
– Marked flow in aortic arch — PDA /AR
• Thrill
– Palpate precordium for thrills and localize where best felt
• Time thrills (systolic vs diastolic)
• Feels like a vibration
– If thrill is felt, then murmur present is at least a grade 4
murmur!!
Heart Sounds
Left sided valves close
before the Right
Left also louder
than Right
First heart sound
Mitral & Tricuspid
closure
Beginning of
isovolemic contraction
Second heart Sound
Aortic & pulmonary
closure
Beginning of
isovolemic relaxation
Heart Sounds
Third Heart Sound
• Rapid ventricular filling in hyperdynamic circulation and thin chest wall
• Abnormal in patients greater than 40 years old
• Best heard early diastole, low pitched, at apex, heard with bell
• Sounds like galloping horse hence gallop rhythm
• Heard in heart failure
Fourth Heart Sound
• Always pathological.
• Low pitched, at apex, heard with bell
• Occurs just before the first sound da-lub dub
• Due to forceful atrial contraction
• Associated with left ventricular hypertrophy (aortic stenosis and
hypertension)
Heart Sounds
• Fixed splitting - ASD
• Single second sound
– Tetralogy of Fallot
– Pulmonary Stenosis
• Other sounds
– Rubs
– Snaps
– Clicks
– Mechanical heart valves
Auscultate the precordium completely
Auscultation
• Listen at each area (apical, tricuspid, pulmonary, aortic )
• Listen exclusively to the individual heart sounds
• Listen to the intervals with the diaphragm and bell
– systole
– diastole
– most troubling murmurs will be medium to high pitched
• Listen to the murmurs
– Is the murmur related to the first or second heart sound?
– What is the quality and pitch?
– What is the intensity?
• Grade 1 to 6 for systolic murmurs
• Grades 1 to 4 for diastolic murmurs
Murmurs
• CAUSED BY:
– TURBULENCE IN BLOOD FLOW
– CARDIAC VIBRATION
• CLASSIFIED BY:
– TIMING
• Systolic between the first and second heart sound
• Diastolic between the second and first heart sound
• Continuous –present continuously through the cardiac cycle
• DYNAMIC MECHANISM
1. Regurgitation -backward flow of blood - MR/TR
2. Obstruction -forward flow of blood – AS/PS ( crescendo-decresendo)
3. Vibration -tissue vibrate from forceful contraction ( musical /innocent)
4. Excessive flow -thru normal orifice or vessel ( innocent)
Murmurs
• Left sided murmurs best heard with the
patient in the left lateral position in expiration
• Right sided murmurs best heard with the
patient in the supine position in inspiration
Plus
• Posterior Chest – scars/lung bases for creps/
sacral oedema
• Examine the abdomen for hepatomegaly and
splenomegaly
• Examine the feet – clubbing, oedema
Common Defects
• Pulse
• Apex Beat
• Murmur
• Radiation
Venticular Septal Defect
• Pulse: Normal
• Apex Beat: Thrusting
• Murmur: Pansystolic
– @ LLSE
– Increases with expiration
• Radiation: No
Mitral Valve Incompetence
• Pulse: Normal
• Apex: Thrusting
• Murmur: Blowing pansystolic murmur
– @ the apex
• Radiates: Yes--- to the axilla
• Accentuation: Expiration
Pulmonary Stenosis
• Pulse: Normal
• Apex Beat: Tapping
• Murmur: Ejection Systolic
– @Upper Left Sternal Edge
• Radiation: To the back
• Accentuation: Inspiration
Patent Ductus Arterious
• Pulse: High Volume, Collapsing
• Apex Beat: Thrusting
• Murmur: Continuous, Machinery
– Left Sternal Edge
• Radiation: Back
Aortic Incompetence/Regurgitation
• Pulse: Bounding, Collapsing
• Apex Beat: Thrusting
• Murmur: Early diastolic
– Left Sternal Edge
• Radiation: No
• Accentuation: Leaning forward, Expiration
Aortic Stenosis
• Pulse: Normal
• Apex Beat: Thrusting
• Murmur: Ejection Systolic
– Upper Right Sternal Edge
• Radiation: Neck
• Accentuation: Expiration
• https://www.youtube.com/watch?
v=wYZbMoWjLEg
• https://www.youtube.com/watch?
v=6YY3OOPmUDA
• https://www.youtube.com/watch?
v=ZUHpAaVpiY8
• https://www.youtube.com/watch?
v=pBXcYvIX8Rk
