PHYSICAL EXAMINATION of the HEART

• Strawberry pink
• Acrocyanosis - bluish
palms and soles
Heart - INFANTS
INSPECTION - Normal findings
•

• Strawberry pink
• Acrocyanosis - bluish
palms and soles
Heart - INFANTS
INSPECTION - Abnormal findings
•

• Central Cyanosis
•

1 Congenital cardiac abnormalities -

without acute respiratory symptoms
2

3
4
Respiratory diseases
5

•
•
Raspberry red
1
1
1

1 Desaturation
Heart - INFANTS
INSPECTION - General signs of health

• Nutritional status • Cardiac Disease:

Responsiveness
•
•
•

• Poor feeding
• Failure to thrive
• Irritability
• Tachypnea
• Clubbing
• Poor overall appearance
• Weakness
Heart - INFANTS
PALPATION - Peripheral pulses
•

• Brachial pulse in the antecubital fossa

• Temporal pulses
• Femoral pulses below the inguinal crease
• Dorsalis pedis, posterior tibialis
Heart - INFANTS
PALPATION - Peripheral pulses

• Normal pulse: sharp rise, firm, well localized

•

• Weak, thready pulses with tachycardia

•

• Myocardial dysfunction, heart failure

•

• Absent or diminuted femoral pulses

•

• Coarctation of the aorta

•

• Full pulses in the feet

•

•
Heart - INFANTS
PALPATION

• Point of maximal impulse

•

1 Not always palpable

2 Interspace higher than adults
2

• Heaves
•

1 Left sternal border - Increased right ventricular

work
2 Apex - Increased left ventricular work
Heart - INFANTS
PALPATION - Thrills
•

• Rough, vibrating quality

• Due to turbulence transmitted to the surface
• Felt with palm or base of fingers
Heart - ADOLESCENT

• Inspection
•

• PMI
•

• Palpation
•

• S1 - before carotid upstroke

• S2 - after carotid upstroke
• S3, S4
• PMI
 Heart - ADOLESCENT
Palpation
• PMI
•

• Location
• Diameter: <2.5cm, 1 interspace
• Amplitude - brisk, tapping
•

• Increased amplitude:
•

• Hyperthyroidism
• Severe anemia
• Pressure and volume overload of left
ventricle - Aortic stenosis, mitral
regurgitation
Heart - ADOLESCENT
Palpation

• PMI
•

• Duration - lasts through the first

2/3rds of systole, does not continue to
S2
• Most useful for identifying
hypertrophy of left ventricle
•

• Sustained High amplitude:

•

Left ventricular hypertrophy

•

• Sustained Low amplitude:

•

•
Heart - ADOLESCENT
Palpation
•

• Right ventricular area

•

• Lower left sternal border in 3rd, 4th,

5th interspaces
• Supine, head of bed elevated to 30
degrees
•

• Marked increase in amplitude -

Volume and pressure overload of
right ventricle
Heart - ADOLESCENT
Palpation

• Pulmonic area
•

• Prominent pulsation
•

• Dilation or increased flow in

pulmonary artery
•

• Palpable S2
•

• Pulmonary hypertension
Heart - ADOLESCENT
Palpation

• Aortic area
•

• Palpable S2 - systemic hypertension

•

• Pulsation - dilated or aneurysmal aorta

Heart - INFANTS
AUSCULTATION - Heart rhythm normal variants
Atrial or ventricular premature beats Normal sinus arrhythmia
• Paroxysmal supraventricular tachycardia or Paroxysmal atrial tachycardia
•

• Common age
Most common Neonates (occurs
dysrhythmia at anyoccurs
in infants, age) at any age Childhood
• Well tolerated by some infants and children
• Healthy
Correlation looking, mildly pale, with
with respiration No tachypnea, and rapid, sustained,
Increases completely
on inspiration, decreases with
expiration
regular HR of 240 bpm or more
Effect of exercise on Eradicated Disappears
tachycardia

Rhythm characteristic Skipped or missed beat, irregularly Gradually faster with inspiration, Suddenly
slower on expiration
occurring
Number of beats Single abnormal beats Several beats, in repetitive cycle
Heart - INFANTS
AUSCULTATION - Heart rhythm

• Paroxysmal supraventricular tachycardia or Paroxysmal atrial tachycardia

•

• Most common dysrhythmia in infants, occurs at any age

• Well tolerated by some infants and children
• Healthy looking, mildly pale, with tachypnea, and rapid, sustained, completely
regular HR of 240 bpm or more
Heart
AUSCULTATION - Heart sounds
•

• Crisp S1 and S2
•

• Split S2 at the base (aortic louder

than pulmonic component)
•

• Fuses as single sound on deep

expiration
Heart
AUSCULTATION - Heart sounds
•

• Distant heart tones

•

1 Pericardial effusion
2

• Mushy, less distinct heart sounds

•

1 Myocardial dysfunction
Heart
AUSCULTATION - Heart sounds
•

• Pulmonic louder than aortic component

•

• Pulmonary hypertension
•

• Persistent splitting of S2
•

• Right ventricular volume load

•

1 Atrial septal defect

2 Pulmonary venous return anomalies
3 Chronic anemia
Heart
AUSCULTATION - Heart sounds

• S3
•

1 Low pitched
2 Early diastolic sound
3 Best heard at lower left sternal border or apex
4 Rapid ventricular filling
5 Normal, frequently heard in children
6

• Gallop
•

• Widely split S2 that varies, with normal HR and

rhythm
•
Heart
AUSCULTATION - Heart sounds

• S4
•

1 Not often heard in children

2 Low frequency
3 Late diastolic
4 Occurs just before S1
5 Decreased ventricular compliance, heart
failure
6

• Gallop rhythm
•

1 Tachycardia plus loud S3, S4 or both

Heart
AUSCULTATION - Heart murmurs - Timing

• Location Midsystolic
• Timing • Begins after S1, stops before S2
• Intensity • Semilunar valves
• Quality
•

• Benign - no associated
abnormal findings Pansystolic/Holosystolic
• Starts with S1, stops at S2
• Regurgitant flow in atrioventricular valves

Late systolic
• Starts in mid or late systole, persists up to S2
• Mitral valve prolapse
Heart
AUSCULTATION - Heart murmurs - Timing

• Location
Early diastolic
• Timing • Starts immeditely after S2
• Intensity • Regurgitant flow in semilunar vales
• Quality
•

• Benign - no associated
abnormal findings Mid diastolic
• Starts a short time after S2
• Turbulence at atrioventricular valves

Late diastolic
• Starts late in diastole, continues up to S1
• Turbulence at atrioventricular valves
Heart
AUSCULTATION - Heart murmurs - Timing

• Location
• Timing
• Intensity
• Quality
•

• Benign - no associated
abnormal findings
Continuous murmur
• Starts in systole, extends into all or part of diastole
• Patent ductus arteriosus
Heart
AUSCULTATION - Heart murmurs - Location
Heart
AUSCULTATION - Heart murmurs - Shape or Configuration

• Location
Crescendo
• Timing• Grows louder
• Intensity
• Quality
Decrescendo
•

• Benign -Grows
• softer
no associated
abnormal findings
Crescendo - Decrescendo
• Rises in intensity, then falls

Plateau murmur
• Same intensity throughout
Heart
AUSCULTATION - Heart murmurs - Intensity
GRADAT
• Location IONS of
MURMU
• Timing RS
• Intensity 1 • Very faint
• Heard only after listener has “tuned in”
• Quality • May not be heard in all positions
•

• Benign - no associated
2 • Quiet
Heard immediately after placing stethoscope on the chest
abnormal findings
•

3 Moderately loud
4 Loud, with palpable thrill
5 • Very loud, with thrill
• May be heard with stethoscope partly off the chest
6 • Very loud, with thrill
• May be heard with stethoscope entirely off the chest
Heart
AUSCULTATION - Heart mumurs

• Pitch
•

• High
• Medium
• Low
•

• Quality
•

• Blowing
• Harsh
• Rumbling
• Musical
Heart - INFANTS
AUSCULTATION - Benign Heart murmurs

• No associated abnormal findings

•

• Closing ductus
•

• Transient, soft, ejection

• Upper left sternal border
Heart - INFANTS
AUSCULTATION - Benign Heart murmurs

• Peripheral pulmonary flow murmur

•

• Soft, slightly ejectile, systolic

• To left of upper left sternal border, in lung
fields and axillae
•

• Inadequate pulmonary artery growth

• Sharp angle at which pulmonary artery
curves
Heart - SCHOOL AGE CHILDREN
AUSCULTATION - Benign Heart murmurs

• Still’s murmur
•

• Grade I-II/VI
• Musical, vibratory
• Multiple overtones
• Early and midsystolic
• Mid/lower left sternal border
• Frequently also a carotid bruit
Heart - SCHOOL AGE CHILDREN
AUSCULTATION - Benign Heart murmurs

• Still’s murmur
•

• Disappears by carotid artery

compression
• Accentuated by increased CO
(fever, exercise)
• Diminishes from supine to sitting to
standing
Heart - SCHOOL AGE CHILDREN
AUSCULTATION - Benign Heart murmurs

• Venous hum
•

• Soft, hollow, continuous

• Louder in diastole
• Below the right clavicle
• Same quality as breath sounds,
frequently overlooked
Heart - SCHOOL AGE CHILDREN
AUSCULTATION - Benign Heart murmurs

• Venous hum
•

• Eliminated by:
•

1 Decreased venous return

2

• lying supine
• changing head position
3 Jugular venous compression
Heart - SCHOOL AGE CHILDREN
AUSCULTATION - Benign Heart murmurs

• Carotid bruit
•

• Early and midsystolic

• Slightly harsh quality
• Louder on the left
• Eliminated by carotid
compression
• May accompany still’s murmur
PHYSICAL EXAMINATION of the GENITALIA

• Strawberry pink
• Acrocyanosis - bluish
palms and soles
Male genitalia - INFANTS
INSPECTION

• Penis
• Testes
• Scrotum
•

• Rugae - present by 40 weeks gestation

• Scrotal edema - due to maternal estrogen
•

• Foreskin - completely covers glans penis,

nonretractable
Male genitalia - INFANTS
INSPECTION - Penis

• Hypospadias • Epispadias
• •

• •

• Urethral orifice at ventral surface • Urethral orifice at dorsal surface

of of glans or shaft of penis of of glans or shaft of penis
Male genitalia - INFANTS
INSPECTION - Penis
•

• Chordee
•

• Fixed downward bowing of penis

• May accompany a hypospadias
Male genitalia - INFANTS
PALPATION - Testes

• From external inguinal ring to scrotum

• Testes:10mm width, 15mm length
•

• Cryptochordism: (3%)
•

• One or both testes can’t be felt in

scrotum or inguinal canal
•

• Scrotum appears underdeveloped

or tight
•

• 2/3rds cases: both descended by 1

year of age
Male genitalia - INFANTS
PALPATION - Testes
•

• Check for swelling at the scrotal sac and

inguinal ring
•

• Size changes when infant cries

• Reducible
• Tender
• Transilluminate
• Listen for bowel sounds
Male genitalia - INFANTS
PALPATION
•

• HYDROCELE
•

• Overlie the testes and spermatic cord

• Not reducible
• Can be transilluminated
• Most resolve by 18 months
Male genitalia - INFANTS
PALPATION
•

• HERNIA
•

• Separate from testes

• Usually reducible
• Does not transilluminate
• Does not resolve
• Silk sign: thickened spermatic cord
• May hear bowel sounds
Male genitalia - INFANTS
PALPATION
•

• HERNIA
•

• Separate from testes

• Usually reducible
• Do not transilluminate
• Do not resolve
• Silk sign: thickened spermatic cord
• May hear bowel sounds
Male genitalia
PALPATION
Tender Non-tender
•

• Check for tenderness

• Epididiymitis • Hydrocele
• Orchitis • Non-incarcerated
• Testicular torsion inguinal hernia
• Varicocele
• Tumor
Male genitalia - SCHOOL AGE CHILDREN
INSPECTION
•

• Precocious puberty
•

• Penis and testes are enlarged, with

signs of pubertal changes
• Due to excess androgens (adrenal,
pituitary tumors)
Male genitalia - SCHOOL AGE CHILDREN
Cremasteric reflex
•

• Scratch the medial aspect of the thigh

• Testis on the side scratched moves upward
Male genitalia - Adolescents
INSPECTION - Penis
•

• Scratch the medial aspect of the thigh

• Testis on the side scratched moves upward

Phimosis Paraphimosis Balanitis

• Tight prepuce cannot be • Tight prepuce that cannot • Inflammation of glans
retracted over the glans be returned once retracted
Male genitalia - Adolescents
INSPECTION - Penis
•

• Scratch the medial aspect of the thigh

• Testis on the side scratched moves upward

Balanoposthitis Gonococcal urethritis Nongonococcal urethritis

• Inflammation of glans and • Profuse yellow discharge • Scanty white or clear
prepuce discharge
Male genitalia - Adolescents
INSPECTION - Penis
•

• Scratch the medial aspect of the thigh

• Testis on the side scratched moves upward

Genital warts Herpes simplex Primary syphilis

• Papules or plaques of • Vesicles and erosions • Red papule becoming a
variable shape painless erosion
Male genitalia - Adolescents
PALPATION - Penis
•

• May be omitted in young, asymptomatic

patient
• Between thumb and first two fingers
• Note any tenderness or induration
Male genitalia - Adolescents
INSPECTION - Scrotum
•

• Skin
• Scrotal contours - swelling, lumps

Epidermoid cysts
• Dome shaped white or yellow
papules and nodules
• Common, multiple, benign
Male genitalia - Adolescents
PALPATION - Scrotum
•

• Use thumb and first two fingers

•

• Testis - size, shape, consistency,

tenderness
• Epididymis - nodular, cordlike
• Spermatic cord - note nodules or
swellings
Male genitalia - Adolescents
Sexual maturity rating (Tanner)

• 5 stages of sexual development involves

changes in penis, testes, scrotum
•

• Delayed puberty
•

• if no signs of pubertal development by 14

years of age
• Caused by constitutional
delay,hypogonadism
Male genitalia - Adolescents
Sexual maturity rating - Stage1

Pubic hair Preadolescent - no pubic hair

- fine body hair (vellus hair) similar to
abdomen

Penis Preadolescent - same size and proportions as in childhood

Testes and scrotum Preadolescent - same size and proportions as in childhood

Male genitalia - Adolescents
Sexual maturity rating - Stage 2

Pubic hair Sparse growth of long, slightly

pigmented, downy hair, straight or only
slightly curled, chiefly at base of penis

Penis Slight or no enlargement

Testes and scrotum • Testes larger

• Scrotum larger, somewhat reddened,
and altered in texture
Male genitalia - Adolescents
Sexual maturity rating - Stage 3

Pubic hair Darker, coarser, curlier hair spreading

sparsely over the pubic symphysis

Penis Larger, esecially in length

Testes and scrotum Further enlarged

Male genitalia - Adolescents
Sexual maturity rating - Stage 4

Pubic hair • Coarse and curly hair as in the adult

• Area covered greater than in stage 3, but not as
great as in the adult, and not including the
thighs

Penis Further enlarged in length and breadth, with

development of glans
Testes and scrotum Further enlarged, scrotal skin darkened
Male genitalia - Adolescents
Sexual maturity rating - Stage 5

Pubic hair Hair adult in quantitiy and quality,

spread to the medial surfaces of the
thighs, but not up over the abdomen

Penis Adult in size and shape

Testes and scrotum Adult in size and shape

Female genitalia - INFANTS
INSPECTION
•

• Clitoris
• Labia majora
• Urethral orifice
• Labia minora
• Hymen - thick, avascular structure
with central orifice, covering
vaginal opening
•

• Milky white discharge, may be

blood tinged
Female genitalia - INFANTS
INSPECTION
•

• Ambiguous genitalia:
•

• Masculinization of female external

genitalia
• May be due to congenital adrenal
hyperplasia
Female genitalia - SCHOOL AGE CHILDREN
INSPECTION
•

• Supine, frog leg position

•

• Labia majora and minora flatten

• Hymenal membrane becomes thin,
translucent, vascular, with edges
easily identified
Female genitalia - SCHOOL AGE CHILDREN
INSPECTION - Hymenal variations

• Septate • Crescent • Annular

Female genitalia - SCHOOL AGE CHILDREN
INSPECTION - Hymenal variations

• Septate
Female genitalia - SCHOOL AGE CHILDREN
INSPECTION - Signs of sexual abuse

• Septate
Female genitalia - SCHOOL AGE CHILDREN
INSPECTION
•

• Labial adhesion or fusion of labia minora

•

• Obscures vaginal and urethral orifices

• May be normal
•

• Vaginal discharge
•

• Perineal irritation
• Foreign body
• Vulvovaginits
• Candida
• Pinworms
• STIs, sexual abuse
Female genitalia - SCHOOL AGE CHILDREN
INSPECTION

• Vaginal bleeding
•

• Vaginal irritation
• Trauma
• Sexual abuse
• Foreign body
• Tumor
• Precocious puberty
•

• Purulent, profuse, malodorous, blood-

tinged discharge
•

• Infiltration
•
Female genitalia - SCHOOL AGE CHILDREN
INSPECTION
•

• Rashes
•

• Physical irritation, sweating

• Candidal or bacterial infections -
Streptococcal
•

• Precocious puberty
•

• Presence of pubic hair before 7 years

old
Female genitalia - Adolescents
INSPECTION

• Inflammation
• Ulceration
• Swelling
• Nodules
• Lesions
• Discharges
Female genitalia - Adolescents
INSPECTION

Bartholin’s gland infection Pediculosis pubis

• tense, hot, tender abscess • Small, red maculopapules
Female genitalia - Adolescents
INSPECTION - Discharges

Physiologic leukorrhea Candida albicans

• Clear white or light yellow • White, curdy, thick
Female genitalia - Adolescents
INSPECTION - Discharges

• Vaginal discharge
•

• Physiologic leukorrhea
• Bacterial vaginosis - gray or white, thin
• Candidal vaginitis - white, curdy
• Trichomonal vaginitis - yellowish
green or gray, frothy
• Foreign body
• External irritants
Trichomonas vaginalis Bacterial vaginosis
• Yellowish green or gray • Gray or white, thin
Female genitalia - Adolescents
INSPECTION - Lesions

Epidermoid cyst Venereal wart Syphilitic chancre

• Round, yellowish • Painless ulcer
cystic nodule
Female genitalia - Adolescents
INSPECTION - Lesions

Secondary syphilis Genital herpes

• Slightly raised, round or oval • Small ulcers on red
papules covered by gray exudate base
Female genitalia - Adolescents
Sexual maturity rating - Stage 1 Sexual maturity rating - Stage 2

Preadolescent - no pubic hair Sparse growth of long, slightly

except for fine body hair pigmented, downy hair,
(vellus hair) similar to that of straight or only slightly curled,
the abdomen chiefly along the labia
Female genitalia - Adolescents
Sexual maturity rating - Stage 3 Sexual maturity rating - Stage 4

Darker, coarser, curlier hair, Coarse and curly hair as in

spreading sparsely over the adults; area covered greater
pubic symphysis than in stage 3, but not as great
as in the adult, and not
including the thighs
Female genitalia - Adolescents
Sexual maturity rating - Stage 5
• Delayed puberty
•

• No breasts or pubic hair development

by age 12
• Usually caused by inadequate
gonadotropin secretion, anorexia
nervosa, chronic disease

Hair adult in quantity and

quality, spread on the medial
surfaces of the thighs, but not
up over the abdomen
Rectal Exam - INFANTS

• Done in newborns to assess anal patency

• Not routine for infants unless there is a
question for patency of anus or an
abdominal mass
Rectal Exam - SCHOOL AGE CHILDREN

• Not routine
• Done whenever intraabdominal, pelvic, or
perirectal disease is suspected
•

• Side-lying or lithotomy
• Ask child to breathe in and out through the
mouth to relax
• Use lubricated, gloved index finger
•

• Note tenderness - infectious/inflammatory

Rectal Exam - ADOLESCENT
Inspection

• Side-lying position
•

• Sacrococcygeal and perianal areas

•

• Lumps
• Ulcers
• Inflammation
• Rashes
• Excoriations
•

• Perianal skin is more pigmented and coarser

than the skin over the buttocks
Rectal Exam - ADOLESCENT
Inspection

• External • Rectal prolapse • Anal fissure

hemorrhoids
Rectal Exam - ADOLESCENT
Digital Rectal Exam
•

• Sphincter tone of anus

•

• Laxity - neurologic diseases

• Tightness - scarring
•

• Tenderness
• Induration
• Irregularities or nodules
Rectal Exam - ADOLESCENT
Digital Rectal Exam

• Rectal mucosa
•

• Nodules
• Irregularities
• Induration
•

• Prostate gland
•

• Identify the lateral and median sulcus

• Size, shape, consistency (rounded,
heart-shaped. 2.5cm long)
• Nodules, tenderness
•

• Note color of fecal matter