Cvs examination paediatrics

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CVS cardiovascular examination paediatrics clinical steps apex beat murmur auscultation

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https://mrcpch.paediatrics.co.uk/cardiovascular/examination-…

Here is a comprehensive, structured guide to the CVS Examination in Paediatrics (MRCPCH/OSCE level):

CVS Examination in Paediatrics

Key Principle: Be Opportunistic!

In infants especially, do the three "quiet things" first before the child becomes unsettled:

Auscultation of heart sounds
Auscultation of breath sounds
Palpation of femoral pulses

1. BEFORE YOU TOUCH - APPROACH AND GENERAL OBSERVATION

Around the room:

Oxygen tank (suggests pulmonary hypertension)
Saturation monitor readings

From a distance (general observation):

Nutritional status - "I would like to plot height and weight on a growth chart"
Work of breathing: respiratory rate, recessions, use of accessory muscles
Cyanosis (central vs peripheral)
Dysmorphic features - the top 3 cardiac syndromes:
- Down syndrome (trisomy 21) - ASD, VSD, AVSD (40-50% have CHD)
- Williams syndrome - supravalvular aortic stenosis, peripheral pulmonary stenosis
- DiGeorge syndrome (22q11) - conotruncal defects (ToF, truncus arteriosus, IAA)
Other: Turner's (coarctation, bicuspid AV), Noonan's (pulmonary stenosis, HCM)

2. HANDS

Sign	Significance
Clubbing	Cyanotic CHD, infective endocarditis
Peripheral cyanosis	Reduced perfusion
Central cyanosis (tongue/mucous membranes)	Right-to-left shunt, severe cardiac failure
Splinter haemorrhages	Infective endocarditis
Capillary refill >2 sec	Poor perfusion / cardiac failure
Osler nodes	Infective endocarditis (painful)
Janeway lesions	Infective endocarditis (painless)
Xanthomas	Familial hypercholesterolaemia

Radial pulse: Rate, rhythm, volume, character

3. ARMS

Blood pressure - measure in right arm; if coarctation suspected, compare both arms and one leg
Radio-femoral delay - suggests coarctation of the aorta

4. FACE

Sign	Significance
Malar flush	Mitral stenosis
Central cyanosis (lips/tongue)	Cyanotic CHD
Pallor (conjunctival)	Anaemia - exacerbates cardiac failure
Jaundice	Haemolysis in endocarditis
High-arched palate	Marfan syndrome
Dysmorphic features	As above (Down's, Williams, DiGeorge)

5. NECK

JVP (less reliable in young children due to short neck)
Carotid pulse - character (slow rising = AS; collapsing = AR)
Suprasternal notch - thumb palpate for thrills (aortic stenosis)

6. CHEST - INSPECTION

Chest shape:
- Pectus excavatum (Marfan, associated with MVP)
- Pectus carinatum
- Harrison's sulcus (chronic respiratory work, seen in unrepaired large VSDs)
- Precordial bulge - suggests chronic cardiomegaly since childhood
Surgical scars (critical in paediatrics!):

Scar	Procedure/Condition
Midline sternotomy	Open heart surgery (VSD repair, ToF repair, Fontan)
Left/right anterolateral thoracotomy	BT shunt, PA banding, coarctation repair
Bilateral thoracotomy scars	Failure of one shunt, second shunt performed
Right thoracotomy	Coarctation repair or right BT shunt
Subclavicular	Pacemaker insertion
Inguinal / femoral	Cardiac catheterisation scars

Visible pulsations - hyperdynamic precordium (volume overload states)

7. CHEST - PALPATION

Abdomen first (in children)

Liver: palpate from RIF upward; >2 cm below costal margin = hepatomegaly (sign of right heart failure or CCF)
Spleen: if hepatomegaly present, check for splenomegaly (infective endocarditis)

Apex Beat

Use both hands to feel both sides of the chest
Normal position:
- Up to age 2: 4th intercostal space, midclavicular line
- Age 2-7: 5th intercostal space, just lateral to MCL
- Over 7 years: 5th ICS, midclavicular line (adult position)
Displaced to left: Cardiomegaly, pectus excavatum, scoliosis
Displaced to right: Dextrocardia (check liver position - Kartagener's syndrome), left diaphragmatic hernia, collapsed right lung, left pleural effusion, left pneumothorax
Character:
- Sustained/forceful = LVH
- Thrusting = volume overload (large L-to-R shunt, MR, AR)
- Tapping = palpable S1 (mitral stenosis)

Left Parasternal Heave

Place heel of hand over lower left sternal edge
Positive heave = RV hypertrophy / RV outflow tract obstruction

Thrills (palpable murmurs = grade 4 or above)

Lower left sternal edge - VSD
Upper left sternal edge - Pulmonary stenosis
Upper right sternal edge - Aortic stenosis
Suprasternal notch - Aortic stenosis / coarctation

8. AUSCULTATION

Approach

Show the child your stethoscope first - demonstrate on yourself or their toy to reduce fear.

Auscultation Areas (sequence)

Auscultate in order: Mitral (Apex) → Tricuspid (LLSE) → Pulmonary (LUSE) → Aortic (RUSE)

Also auscultate:

Axilla - if murmur at apex (MR radiation) or LUSE
Back - if murmur at LUSE (PS, PDA)
Neck - if murmur at RUSE (AS radiation)
Lung bases - for inspiratory crepitations (left heart failure / pulmonary oedema)

Heart Sounds

Sound	Normal	Abnormal
S1	Single, best at apex	Loud = MS (tapping apex beat)
S2	Physiological split on inspiration (normal in children!)	Fixed split = ASD; Wide split = RBBB/PS; Single = pulmonary hypertension / severe AS
S3	Can be normal in children	Pathological in adults = ventricular dysfunction
S4	Abnormal	Reduced ventricular compliance

Important: Physiological splitting of S2 is NORMAL in children - do not call it pathological.

Murmur Grading (Levine scale)

Grade	Description
I/VI	Very soft, only with concentration
II/VI	Soft but immediately audible
III/VI	Moderately loud, no thrill
IV/VI	Loud + thrill
V/VI	Very loud, heard with stethoscope edge only
VI/VI	Audible without stethoscope

Murmur Characterisation

For every murmur describe: Timing - Location - Radiation - Quality - Grade

Area	Murmur type	Diagnosis
ULSE	Ejection systolic	Pulmonary stenosis, ASD, Innocent murmur
RUSE	Ejection systolic	Aortic stenosis
RUSE	Continuous	BT shunt, venous hum
LLSE	Pansystolic	VSD
Apex	Pansystolic	Mitral regurgitation, VSD
Apex	Late systolic	Mitral valve prolapse
Apex	Mid-diastolic	Mitral stenosis
LUSE/back	Continuous machinery	PDA

9. INNOCENT MURMURS ("Still's murmur")

Features of an innocent murmur (the 7 S's):

Systolic (never diastolic or continuous except venous hum)
Soft (grade I-II/VI)
Short
Sternal (or left sternal edge)
Special quality (musical/vibratory/buzzing)
Sitting/standing changes it (position-sensitive)
Symptom free

When a soft grade I-II/VI midsystolic murmur occurs in an asymptomatic child with no other evidence of heart disease, it is usually benign and echocardiography is generally NOT required. - Harrison's Principles of Internal Medicine 22E

10. COMPLETING THE EXAMINATION

State you would like to:

Measure blood pressure and oxygen saturations (4-limb BP if coarctation suspected)
Palpate femoral pulses and check inguinal area for cath scars
Check for peripheral and sacral oedema
Plot height and weight on appropriate growth chart
Examine the lung bases for crepitations
Request: ECG, CXR, echocardiogram

11. HOW TO PRESENT FINDINGS

Keep it concise and focused:

"This is a [age] year old child who is [pink/cyanosed], [comfortable/in respiratory distress], with [no clubbing / digital clubbing]. There is a [midline sternotomy / no] scar. Heart sounds I and II are [normal/described], with a [grade X/VI ejection systolic/pansystolic] murmur heard best at [location], radiating to [neck/axilla/back]."

Quick Reference: Common Paediatric Cardiac Conditions

Condition	Key Exam Finding
VSD	Pansystolic murmur LLSE, thrill at LLSE
ASD	Fixed split S2, ejection systolic at ULSE
PDA	Continuous machinery murmur LUSE, collapsing pulse
Pulmonary stenosis	Ejection systolic ULSE + ejection click, left parasternal heave
Aortic stenosis	Ejection systolic RUSE radiating to neck, slow-rising pulse
Coarctation	Radio-femoral delay, hypertension right arm, reduced femoral pulses
ToF	Cyanosis, clubbing, right parasternal heave, ejection systolic (PS), single S2
Mitral regurgitation	Pansystolic apex radiating to axilla, thrusting apex

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