THE

CARDIOVASCUL
AR SYSTEM
History and Physical Examination
Congenital Heart Diseases
Acquired Heart Diseases
HISTORY AND
PHYSICAL
EXAMINATION
Justin W. Ng Sinco
THE IMPORTANCE
 Increases the accuracy of echocardiography
 Eliminate unnecessary and expensive laboratory
tests
 Reassure family and prevent unnecessary
restrictions on physical activity
IMPORTANT POINTS
 Perinatal History
 Cyanosis
 Respiratory distress
 Prematurity
 Maternal complications (GDM, SLE, substance abuse)

 Age-specific symptoms of heart failure

 Infants – feeding and respiratory distress
 Older children – exercise intolerance, chronic abdominal
complaints
IMPORTANT POINTS
 Cyanosis – at rest and during crying or exercise
 Chest pain – unusual manifestation of cardiac
disease
 Most commonly due to musculoskeletal or pulmonary
diseases
 Careful evaluation if with history of KD or CHD repair
IMPORTANT POINTS
 Cyanosis – at rest and during crying or exercise
 Chest pain – unusual manifestation of cardiac
disease
 Most commonly due to musculoskeletal or pulmonary
diseases
 Careful evaluation if with history of KD or CHD repair

 Association with a malformation syndrome

 Association with a generalized disorder affecting
the heart
IMPORTANT POINTS
 Family History
 Early CAD or stroke – familial hypercholesterolemia,
thrombophilia
 Sudden death – cardiomyopathy, familial arrhythmic
disorder
 Generalized muscle disease – muscular dystrophies,
dermatomyositis, familial or metabolic cardiomyopathy
 1 st -degree relatives with CHD
PHYSICAL EXAMINATION –
APPEARANCE
 Cyanosis
 nail beds, lips, tongue, mucous membranes
 Differential cyanosis, acrocyanosis, circumoral cyanosis,
blueness around the forehead
 Growth
 Chest wall
 Respiratory distress
 Murmurs
 Clubbing – usually manifests in the late 1 st year of
life
PHYSICAL EXAMINATION
 Signs of heart failure
 Hepatomegaly
 Splenomegaly
 Peripheral edema
 Infants – periorbital and fl anks
 Older children – periorbital and pedal
PHYSICAL EXAMINATION –
HEART RATE
 Newborns – rapid heart rate with wide fluctuations
 120-140 bpm; 170+ bpm during crying and activity to
70-90 bpm during sleep.
 Older children – as low as 40 bpm at rest in
athletic adolescents.
PHYSICAL EXAMINATION –
HEART RATE
 Persistent tachycardia
 >200 beats/min in neonates
 >150 beats/min in infants
 >120 beats/min in older children

 Bradycardia
 Irregular heartbeat
PHYSICAL EXAMINATION –
HEART RATE
PHYSICAL EXAMINATION –
PULSES
 Wide pulse pressure with bounding pulses
 PDA, aortic insuffi ciency, AV malformation
 Increased cardiac output
 anemia, anxiety, or conditions associated with increased
catecholamine or thyroid hormone secretion
 Diminished pulses
 pericardial tamponade, left ventricular outfl ow
obstruction, or cardiomyopathy
 Radial and femoral arteries palpated simultaneously
 femoral pulse should be appreciated immediately before
the radial pulse.
PHYSICAL EXAMINATION –
BLOOD PRESSURE
 Measured in both upper and lower extremities
 10 mm Hg higher in the legs than the arms

 The cuff should cover approx. 2/3 of the length of

the arm or leg
 Lower extremities
 Cuff: legs
 Stethoscope: popliteal artery
PHYSICAL EXAMINATION
 Jugular venous pulse
 Neck veins inspected
while sitting at a 90-
degree angle
 Signs of increased venous
pressure
 External jugular vein visible
above the clavicle
 Visible pulsations of the
internal jugular vein (sitting
at a 45-degree angle)
CARDIAC EXAMINATION
 Hyperdynamic
precordium

From Dr. M. M. Haque,

https://www.youtube.com/watch?
CARDIAC EXAMINATION –
INSPECTION & PALPATION
 Precordial bulge
 Assessed with the child supine and M.D. looking up from
the feet
 Substernal thrust – RVE
 Apical heave – LVE
 Overly silent precordium – pericardial tamponade,
severe cardiomyopathy, obese
 Apical impulse
CARDIAC EXAMINATION –
INSPECTION & PALPATION
 Thrills
 Right lower sternal systolic thrills – VSD
 Apical systolic thrills – Mitral insuffi ciency
 Diastolic thrills – AV valve stenosis
CARDIAC EXAMINATION –
AUSCULTATION
 Technique
 Diaphragm placed firmly for high-pitched sounds
 Bell placed lightly for low-pitched sounds
 Focus on individual heart sounds and their variations
before concentrating on murmurs
 Patient: supine, quiet, breathing normally
 1 st heart sound – apex
 2 nd heart sound – upper left and right sternal borders
 3 rd heart sound – apex (bell), mid-diastole
 4 th heart sound – heard just before the 1 st heart sound
 From Guyton & Hall. Textbook of Medical Physiology, 13th e
From Nelson’s
Textbook of
Pediatrics, 20th
CARDIAC EXAMINATION –
AUSCULTATION
 Splitting of the 2 nd heart sound
 Normal during inspiration
 Wide split – atrial septal defect, pulmonary stenosis,
Ebstein anomaly, total anomalous pulmonary venous
return, and right bundle branch block
 Narrow split – pulmonary hypertension
 No split (single sound) – pulmonary or aortic atresia,
severe stenosis, truncus arteriosus, ToGA
CARDIAC EXAMINATION –
AUSCULTATION
 3 rd heart sound
 Normal in adolescents in slow heart rate
 Heart failure or tachycardia  Gallop rhythm

 Ejection clicks – early systole (“split S1”)

 Aortic – left middle to right upper sternal border,
constant intensity
 Pulmonary – left middle to upper sternal border and
vary with respirations, often disappearing with
inspiration
 Aortic or pulmonary valve stenosis
 Dilated ascending aorta (TOF, TA) or pulmonary artery
CARDIAC EXAMINATION –
MURMURS
 Intensity
 Pitch
 Timing
 Variation in intensity
 Time to peak intensity
 Area of maximal intensity
 Radiation
CARDIAC EXAMINATION –
MURMURS

Image from:
http://hypocaffeinic.pbworks.com/w/page/54034750/CAP101%20-
%20p7%20-%20Murmurs%20and%20miscellaneous
CARDIAC EXAMINATION –
MURMURS
 Murmur intensity grading
I – barely audible
II – medium intensity
III – loud but no thrill
IV – loud with a thrill
V – very loud but still requiring positioning of the
stethoscope at least partly on the chest
VI – can be heard with the stethoscope off the
chest
CARDIAC EXAMINATION –
MURMURS
 Timing – systolic or diastolic
 Systolic ejection
 Pansystolic or holosystolic
 Continuous
CARDIAC EXAMINATION –
MURMURS
 Absence of a murmur does not rule out significant
heart disease
 In contrast, loud murmurs may be present in the
absence of structural heart disease, for example,
in patients with a large noncardiac arteriovenous
malformation, myocarditis, severe anemia, or
hypertension.
INNOCENT MURMURS
 More than 30% of children may have an innocent
murmur at one time in their lives
 Most common innocent murmur
 medium-pitched, vibratory or “musical,” relatively short
systolic ejection murmur, which is heard best along the
left lower and midsternal border and has no significant
radiation to the apex, base, or back.
 3 – 7 years old
 Attenuated in the sitting or prone position
 Varies with respiration
INNOCENT MURMURS
 Innocent pulmonic murmurs in children and adolescents
 higher pitched, blowing, brief early systolic murmurs of grades
I-II in intensity and are best detected in the 2 nd left parasternal
space with the patient in the supine position
 Turbulence in ejection into pulmonary artery

 Venous hum
 soft humming sound heard in both systole and diastole;
exaggerated or made to disappear by varying the position of
the head or it can be decreased by lightly compressing the
jugular venous system in the neck
 heard in the neck or anterior portion of the upper part of the
chest.
 Turbulence in jugular venous system This is the last slide. Thank you.