CVS Examination

Dr.Prasenjit Das, PGT

Moderator: Dr.B.Nath, Associate Professor
Pertinent Questions
• Does the child have a heart disease?
• If yes, is it congenital or acquired?
• What is the type of lesions?
• What is the severity of lesion?
NADAS’ Criteria
• Major criteria:
Systolic murmur with thrill (>gr3)
Any diastolic murmur
Cyanosis
Congestive cardiac failure
Minor Criteria
• Systolic murmur without thrill
• Abnormal P2
• Abnormal BP
• Abnormal CXR
• Abnormal ECG
One major or 2 minor criteria indicates
heart disease
Objectives
• History
• Symptoms
• General Examination
• Inspection
• Palpation
• Auscultation: Heart sounds, added sounds
• Examination of other systems
RELEVENT HISTORY
HISTORY RELEVENT INFORMATION

Antenatal history Maternal infections, metabolic disorders, drugs

Growth and development Genetic syndromes, maternal infections, drugs

Nutritional history Malnutrition, anaemia

Family history Consanguinity, heart disease, sudden death

Treatment Medications, surgery, prophylaxis

Chronology of cardiovascular lesions
Within the first few hours Pulmonary or aortic atresia, critical stenosis, Hypoplastic of left
heart syndrome

Within the first few days TGA, TOF, HLHS, PDA in preterm

Within the first few weeks Critical aortic stenosis, CoA

Within first few months Left to right shunts

After 4-5 years ARF/RHDs and other CHDs

Presenting symptoms
• Chest pain
• Breathlessness:
Dyspnea on exertion
Orthopnea
Paroxysmal dyspnea
Dyspnea at rest
• Palpitation
• Sweat on the forehead
• Neurological symptoms- H/O stroke, headache, chorea, Syncope.
Chest pain
• Causes of chest pain in children: Cardiac causes are rare.
• Musculoskeletal (myalgia, costochondritis)-30-40%
• Pulmonary: pleuritis, severe asthma, pneumonia)- 10-15 %
• GI : GERD, esophagitis, gastritis- 5-10%
• Cardiac condition- pericarditis, severe aortic stenosis, kawasaki
disease, ALCAPA -1-3%
• unknown-25-35%
Breathlessness
• Dyspnea on exertion:
• Orthopnea: Dyspnea on lying down
• Paroxysmal nocturnal dyspnea: Acute severe breathlessness that
wakes the patient from sleep.
• Dyspnea at rest: advanced cardiac disease.
Palpitation
• Subjective feeling of rapid heart beats.
• Often incorrectly reported by children.
Sweating of forehead
• Cold sweating of forehead is a feature of CCF.
• It is due to increased sympathatic activity as a result of reduced
cardiac output.
Neurological symptoms
• H/O stroke- embolism or thrombosis.
• Headache: may be due to cerebral hypoxia with cyanotic heart
disease.
• Hypertensive encephalopathy.
• Choreiform movements.
• Syncope.
Failure to thrive
• In congenital heart disease height and weight are equally affected.
• Acquired heart disease weight is affected more than the height.
 Cyanotic spells
Paroxysms of hyperapnea, restlessness, increased
cyanosis and gasping respiration followed by
syncope. OP Ghai add
Migratory polyarthritis
• Large joints
• Hot, red, swollen and exquisitely tender.
• Migratory- involved joint become normal within 2-3 days without any
treatment.
• D/D- JIA
• Dramatic response to salicylates.
Chorea
• Neurobehavioral disorder occurs in about 10-15 % in ARF.
• Sydenham chorea.
• Clinical signs to elicit chorea:
Milkmaid’s grip
Spooning and pronation of hands
Wormian movement of the tongue
Fine tremor while writing
Recurrent respiratory infection
• Bacterial pneumonia 4-5 times per year.
History taking
• Antenatal history
• Maternal conditions
• Birth weight
• Weight gain, development
• Feeding pattern
• Recurrent respiratory infection
• Family history and socio-economic history
General examination
• Appearance • Cyanosis
• Decubitus • Clubbing
• Face and hands • Pallor
• JVP • Pulse / heart rate
• Neck glands • Respiratory rate
• Edema • Blood pressure
• Anthropometry and assessment
nutritional status
Appearance
• Distress
• Playful
• Ill looking
Decubitus
• Position of the child in which he/she is comfortable gives important
clue as to whether the child is in heart failure or not.
Face and hands
• Should be examined for dysmorphism.
• Flat nasal bridge
• Hypertelorism
• Mongoloid and antimongoloid slant of the eyes.
• Simian crease
JVP

• JVP- between two heads of SCM

• >4cm - abnormal
• Neck veins may be engorged in
CCF, pericardial effusion,
constrivtive pericarditis, and
mediastinal mass
a wave - atrial contraction
c wave- Upward bulging of tricuspid
valve during isovolumetric
contraction
x descent- right atrial relaxation
v wave- passive atrial filling in late
systole with tricuspid valve closed
y descent- opening of the tricuspid
valve
Abnormal ‘a’ wave
• Cannon ‘a’ wave- right atium contracts against closed tricuspid valve,
tricuspid atresia, AV dissociation & complete heart block.
• Gaint ‘a’ wave - tricuspid stenosis, right atrial myxoma, severe PAH.
• Absent ‘a’ wave- AF
Edema
• Difficult to detect in young
infants.
• Puffiness of face
• Unexplained weight gain.
Cyanosis
• Derived from Greek word ‘
kyanous’- blue.
• Definition
• Cyanosis should be checked
against the hematocrit.
• Cyanosis associated with arterial
desaturation - central cyanosis
• Cyanosis associated with normal
saturation- peripheral cyanosis.
• Normal in newborn-
acrocyanosis.
• Cirumoral cyanosis may be
normal in newborn.
• Differential cyanosis:
Clubbing
• Subcutaneous swelling involving
the root of the nails resulting in
softening of the nail and
fluctuation.
• Long standing cyanosis results in
clubbing.
Causes of clubbing
C- Cyanotic group of congenital heart disease
Cystic fibrosis
L- lung abscess/ lung cancer
U- ulcerative colitis
B- bronchiactasis
B- benign mesothelioma
I- infective endocarditis
ideopathic pulmonary fibrosis
N- neurogenic tumour
G- GI disease
Pallor
• Seen in infants with
vasoconstriction from CCF,
Circulatory shock or severe
anaemia.
Pulse
• Radial pulse is examined with
tips of the index and middle
fingers compressing against the
lower end of radius.
• Rate
• Rhythm
• Volume
• Character
• Symmetry
Pulse cont.
• Peripheral pulses
• Abnormal pulses:
Pulsus alternans
Pulsus bigeminus
Bounding
Bounding
Collapsing
Pulsus paradoxus
• Pulsus alternans : strong, high
volume pulse alternating with
weak, low volume pulse. LVF,
myocarditis
• Pulsus bigeminus: Regular
premature ventricular ectopics
occuring alternately after normal
beats. AV block
• Bisferiens pulse: Two palpable
impulse in rapidly rising systolic
upstroke. AR, HOCM
Water hammer pulse
• A large volume pulse with
abrupt and rapid upstroke with
an equally rapid downstroke.
Causes of tachycardia
• Sinus tachycardia:
Fever
Exercise
Emotional disturbances
Anaemia
Dehydration
Shock
Myocarditis
Cardiac failure
• Sinus tachycardia:
Pulmonary embolism
Thyrotoxicosis
Pheochromatosis
Hypoglycemia
• Bradycardia:
Bradyarrhythmias: Sinoatrial block, AV block, complete bundle branch
block, sick sinus syndrome, long QT syndrome.
Athletic child
Hypothermia
Hypoxia
Hypothyroidism
Acidosis
Raised ICT, Brainstem compression, Excessive vagal tone.
Temperature
• Bacterial endocarditis
• ARF
• Pulmonary infarction
• Chest infection
Respiratory rate
• Tachypnea-
CCF
 anoxic spells
 pulmonary emboli
Intercurrent chest infection
Blood pressure
• Cuff size: completely or nearly
encircle the extremity. Width
sould be 40% of arm
circumference (AHA ).
• The cuff is wrapped about 2.5
cm above the cubital fossa.
• Average of 2 or more reading
• The child should in sitting
position with arm at the heart
level.
• Method:
Criteria for HTN

Diagnosis of hypertension should be

made by consulting the percentile
chart.
Blood pressure flush method
• Cuff is wrapped around te arm.
• Limb is raised vertically and held above the head till palm becomes
pale.
• BP cuff is raised beyond expected SBP.
• Arm is broght down to the side and cuff is gradually deflated.
• Point at which palm becomes flushed, systolic BP.
CVS examination
• Systemic examination of CVS
includes inspection, palpation
and auscultation.
• Percussion of heart is avoided.
• Auscultation may be done
before inspection.
Inspection
• Inspection of Precordium:
Precordium refers to the anterior chest wall area overlying the heart.
Shape of the precordium (Early deformity < 5yrs- CHD)
Right heart border:
Left heart border:
Inspection of Precordium
• Symetry and shape of chest wall.
• Visible scar mark
• Pectus carinatum
• Pectus exacavatum
• Harrison sulcus
Pectus excavatum
Pectus carinatum
Precordial bulge due to CHD
• Apical impulse
• Pulsation over:
 Left parasternal
Epigastric
Suprasternal
Epigastric pulsations: • Left 2nd ICS:pulmonary artery
 RVH dilatation
Transmitted aortic pulsation
Around the nipple: LVH/ Suprasternal notch: Dilated arch
dilatation of aorta
Left parasternal region: RVH/
dilatation
• Apical Impulse
• Location and character of apical impulse, if it is visible.
• Diffuse apical impulse- Hyperdynamic condition
• Displacement out and/or down indicate cardiac enlargement.
• Venous prominence:
Palpation
• Position of trachea
• Apex beat: location, character, associated thrill
• Pulsation in the pulmonary, left parasternal, suprasternal, epigastric
region
• Point of maximum impulse
• Heave & thursts
• Thrill
• General rule :
• Fingertips: To feel pulsations
• Base of fingers: Thrills
• Base of hand( or ulnar aspect) :
Heaves
Apex beat
• Outermost and lowermost point of palpable impact of cardiac
impulse.
• Angle of Louis: important landmark
• Location of apex beat- up, down and out, outwards, inwards and right
side.
• Character: Normal/ feeble/ tapping/ heaving/hyperkinetic.
Normal variation in location of apical impulse with
age
Age Position of apical impulse Relation to
midclavicular
line

Infancy Left 4th ICS Lateral to mid clavicular line

approx 5 years Left 5th ICS In the Midclavicular line

Older children Left 5th ICS Medial to midclavicular line

 Apical impulse/apex beat

Absent/
Hyperdynamic Heaving Tapping
feeble

Dextrocardia
Hyperdynamic
Behind the
circulatory state
rib AS Mitral stenosis
High cardiac MR
obesity HCM
output states VSD
Pericardial Severe left
Pectus PDA
effusion ventricular
exacavatum A-V fistula
DCM dysfunction
Thin chest wall
• Hyperdynamic (forceful/ ill sustained): Rapid, brisk, large amplitude,
upstroke, occupying > 1 IC space, exceding 3cm
 ill sustained: Duration between 1/3 to1/2 of systole
• Heaving (sustained) apex: Sustained systolic thrust with increase in
duration for >2/3 of systole, confined to one ICS.
PARASTERNAL PULSATIONS AND
HEAVE
• A palpable thrust, which lifts the palpating hand
• Seen in RVH and Left atrial enlargement
• Palpated by ulnar aspect of hand
• Grading :
I. Instant lift, visible not palpable
II. Visible and palpable, lift can be obliterated
III. Visible and palpable, lift cant be obliterated
• Precordial pulsations:
• Pulmonary area: systolic pulsation- pulmonary arterail dilatation.
• Suprasternal pulsation: AR, PDA, CoA, aortic aneurysm.
• Epigastric: Right ventricular hypertrophy. (ADD )
• Palpable 1st heart sound: MS
• second heart sound: PAH
Thrills
• Palpable vibrations of murmurs which accompany any organic
murmur of grade 4 or more.
• Systolic thrill: Mitral area- MR
• Aortic area: AS
• Pulmonary area: PS
• Left parasternal area: VSD.
• Over carotids: AS
• Diastolic thrill:
• Apex or internal to apex: MS
• 3rd LICS lateral to sternal border: AR
• Continuous thrill: 2nd LICS, left supraclavicular: PDA
Auscultation
• Areas for auscultation:
• Apex: Mitral area
• Aortic area & 2nd aortic area
• Tricuspid area
• Pulmonary area
• Other area( piyush gupta)
• First and 2nd hert sounds
• Extra heart sounds (3rd & 4th sounds)
• Additional sounds: ejection clicks, opening snap, pericardial rub
• Murmurs
Heart sounds
• First heart sound(S1): Closure of tricuspid and mitral valve.
• S1 signifies the onset of systolic interval.
• S1 best heard over the apical impulse in mitral area.
• Intensity and character.
• Soft- MR, Loud- MS.
• Distant- pericardial effusion
• Muffeled: Myocarditis.
• 2nd heart sound: Left 2nd intercostal space.
• It is of critical importance in Pediatric cardiology.
• Splitting and intensity of closure of A2 & P2.
• Soft- low cardiac output, severe PS, TOF, TS,AR & calcific stenosis.
• Loud- systemic hypertension- aortic component, Pulmonary HTN-
Pulmonary component.
Splitting
• physiological spilitting: Ispiration

• Increase negative intrathorcic pressure

• Increase systemic venous return to right side of heart

• Increase volume of blood in right ventricle prolonged the duration of

ventricular ejection which delays the closure of pulmonary valve

• Physiological splitting
Abnormal splitting of S2
• Wide split and fixed:
Volume overload (ASD, TAPVR)
Electrical delay (RBBB, WPW syndrome)
Early aortic closure (MR)
• Wide and variable split:
PS
MR
VSD
PAPVC
• Narrowly split:
Pulmonary hypertension
Aortic stenosis
• Single S2:
Pulmonary hypertension
One semilunar valve(PA,AA)
P2 not audible (TGA, TOF, Severe PS)
Severe aortic stenosis
• Paradoxical split:
Severe aortic stenosis
LBBB, WPW syndrome
PDA and post stenotic dilatation of aorta
Severe hypertension
Aortic regurgitation
3rd heart sound
• Best heard at the apex.
• It may be normal in children and young adults.
• Loud 3rd heart sound is abnormal.
• Large, heart failure
• Rapid filling of ventricles during early diastole
4th heart sound
• Always pathological.
• Atrial contraction
• Heard in cases with decreased ventricular compliance or CCF.
• Presence of 3rd or 4th heart sound results in triple rhythm.
• Triple rhythm+ tchycardia : gallop rhythm.
Opening spap
• High frequency sound.
• Opening of stiff mitral valve
• In diastole, immediatel after 2nd heart sound.
• Best heard in expiration at 4th ICS over left strenal border.
Ejection click
• Sounds like splitting of first heart sound because it closely follows 1st
H.S.
• Aortic ejection click 2nd right ICS.
• Pulmonary ejection click left 2nd & 3rd ICS.
• Pulmonary and aortic stenosis.
Pericardial friction rub
• Grating to and fro sound produced by friction of the heart against the
pericardium.
• Intensity varies with the cardiac cycle.